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Preventing Burnout Through Self-Care [Ethics and Risk Management]

by William W. Deardorff, Ph.D, ABPP.

3 Credit Hours - $69
Last revised: 09/10/2018

Course content © Copyright 2018 - 2022 by William W. Deardorff, Ph.D, ABPP. All rights reserved.


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“….it has always struck me as an extraordinary privilege to belong to the venerable and honorable guild of healers.  We therapists are part of tradition reaching back not only to our immediate psychotherapy ancestors, beginning with Freud and Jung and their ancestors – Nietzsche, Schopenhauer, Kierkegaard – but also to Jesus, the Buddha, Plato, Socrates, Galen, Hippocrates, and all the other great religious leaders, philosophers, and physicians who have, since the beginning of time, ministered to human despair”


Irvin Yalom, The Gift of Therapy (2002)


“Empirical research attests to the negative toll exacted by a career in therapy. The literature points to depression, mild anxiety, emotional exhaustion and disrupted relationships as the common residue of immersion in the inner worlds of distressed and distressing people”


Vivian Baruch (2004)


There's an old saying that goes "I’ve never seen a tombstone that reads, 'I wish I had worked harder.'



Course Outline


Learning Objectives

Introduction and Defining the Problem

Distress among Mental Health Professional: The Problem is Real


Compassion Fatigue

Secondary Traumatic Stress and Vicarious Trauma

Traumatic Countertransference



Occupational Hazards and Vulnerabilities in Practice

The Physical Demand of the Work

Physical isolation

Sedentary work and sensory deprivation

Emotional and Psychological Nature of the Work

One-way intimacy



Attributes of the patient

Working with trauma survivors

“Working through” as a treatment technique

Personal Attributes of the Therapist

The dedicated and committed worker burnout

Over-commitment with sub-satisfactory outside life

The authoritarian burnout

The over-involved professional

Systems Issues

Work setting

Managed care

The Development of Compassion Fatigue and Burnout

Compassion Fatigue


Preventing Burnout: Incorporate Self-Care Activities Into Your Life

Beyond Burnout:  Impairment

Ethical Codes, Burnout, and Impairment





Learning Objectives



Explain compassion fatigue and burnout


List two physical demands of mental health work


List four emotional and psychological vulnerabilities for burnout


List eight self-care methods for preventing burnout


Discuss the ethical mandates and methods to intervene with an impaired colleague





The following recent blog posts underscore the process of burnout.  As can be seen, a neuroscientist is “burned out” in her position doing research.  She is thinking about re-treading and entering the field of mental health care.  She poses an interesting question in an effort to make an informed decision about her plans.  Given the nature of the question, the responses are decidedly negative.  As will be seen in this course, virtually all of these responses contain elements of burnout. These sentiments can be contrasted with the quote from Dr. Yalom at the beginning of the course.  Clearly, his quote represents the well-balanced life of a psychotherapist.



What might I hate about becoming a therapist? 



The question posed on the blog:

I’m looking for candid opinions about why NOT to become a therapist. Of course, I’d like perspectives about why it is a good idea, as well, but I need some reality. For reference, I have a Ph.D. in Neuroscience, and as a post-doc I’m finding that I hate research. Therapy appeals to me because I am certain I will like a larger portion of my colleagues. The process of my own therapy has fascinated me.


The Responses:


My mom was an MSW therapist who retired, in part due to the changing insurance landscape. Some down sides: The hassles of dealing with insurance companies, as most insurance companies will only pay for brief therapy, even if it was something extremely serious. People often did not have the funds to pay for continuing therapy. She also said that when she started in the 1970s, 1 hour of therapy required 20 minutes of paperwork and that by the 1990s, that had reversed. These two problems are what led her to retire in her late 40s.

As a retired psychologist, what I found most tiresome, as the years went on, was spending so much of my life in mono-directional relationships. It's not like other work places where after working together all day you might go out with co-workers. After work is done, you can be left with a lot negative stuff, despite your knowledge of transference and how to handle it.  I found it rather depressing to hear depressed people talk about how depressed they are.

My wife is a counselor and while there are many things she likes about it- you asked why you might hate it. - Shaking off bad stuff - Therapy from the therapist's perspective can be a lonely profession. So you have to actively develop friendships with people who are not therapists if you want to talk about something unrelated – You have to be accustomed to dealing with your clients at unexpected times - If you are going into business for yourself the whole billing process (insurance is part of this) is a major pain – And, speaking from someone who is the spouse of a therapist, dealing with unbalanced people all day long will sometimes make you unbalanced, so make sure you have a good support system at home.

Don't forget the ethical dilemmas. That's a good thing to read up on. I took a class about ethical dilemmas and therapy and it really made me not want to be a therapist.

Being a therapist can be a very lonely profession. In private practice it's just you in an office, no colleagues. Even in agency settings there can be a lot of alone time depending on patient load and the number of people you work with. For instance, I'm the only therapist at the medical clinic where I work, and medical personnel, while very caring, have a completely different attitude toward patients.

Insurance can be tough, and many people find it better to have both an agency job and a private practice in order to secure benefits, so many therapists I know work longer hours than they might have started out thinking they would.

There's also, frankly, a battle going on for the soul of mental health treatment. It's been going on for quite a while, and there are many gray areas where there's common ground, but there's an awful lot of emphasis put on the assumption of physical causes for mental disorders, even in the face of shaky evidence. Part of this comes from pharma-funded studies of medication efficacy, part of it comes from pressure within medicine toward psychiatry, part of it comes from capitulation on the part of social workers and other therapists. It can be frustrating to fight for a central rather than an adjunct position in mental health treatment. It can be tiring to have people suggest in various ways that at best psychotherapy operates at the level of amelioration.

Do you want to be the only sympathetic person that someone can complain to? I know you are supposed to focus away from listening to complaints and toward some sort of treatment, but many customers want to pay for sympathy.

Regularly seeing people who are unlikely to improve much or ever really be happy strikes me as a tough, tough career.

Sometimes, after 8-10 hours of engaging people, establishing rapport and making conversation empathetically, I don't have much energy to engage the other people in my own life. My emotional exhaustion tends to cause me to withdraw from others. That's probably a personality thing that's unique to only certain types of people.

There was high turnover because many people stop coming once their insurance-allocated visits run out; an average of 2 new patients started every week. And at least 2 patients per week would cancel appointments due to difficulties that would come up in their lives. The therapist was constantly looking for new places to list the practice in order to generate a steady stream of patients.

The only therapist I've known personally got out of therapy a few years before I met him. He said that he started out liking the work, but over the years the strain and despair of dealing with the hopelessly damaged really got to him. Like a previous post said, watching folks make the same mistakes over and over again can be a real drag.

There is nothing more frustrating than being able, over months and visits, to a) be able to apprehend the problems in someone's life; b) devise a clear path to freeing them of those problems, and c) come up against the fact that deep down they really don't want to change. It can feel like a colossal waste of your time. That said, if you're called, it's worth doing, despite all of the above.

When you're in a service related profession, the business aspects can be difficult. You need to be paid and your clients may not be able to pay you.

My mom has been an MFT for many years. There are lots of things that stress her out about it. The obvious things, I think, are the sadness and frustration that comes with dealing with people when they're at their worst and during the worst times in their lives. It was hard not to take it home. Also she would sometimes get threats from clients or their family members, making her really scared for herself and the rest of the family.

The other big thing is that if you're working within any sort of system or program or the government, you may not be free to practice the kind of therapy that you feel is most appropriate.

My mother was a therapist in private practice. I know that she was about ready to leave the profession altogether after 20 years, because of the insurance issues mentioned above. Not how much she was reimbursed, but because of the TOTAL NIGHTMARE to get the reimbursement. It's a lot worse than you imagine.






stressed therapist


Conceptually, all mental health practitioners are always functioning on a continuum from “well” to “impaired”.  The prevalence of mental of emotional disorders in the United States is approximately 21%.  However, research suggests that this rate may be higher in those who work in the mental health and health services fields.  For a number of reasons that will be reviewed in this course, mental health professionals may be more vulnerable to distress (of all intensities) for a number of reasons.  This can range from the usual mild work-related stress to a fully developed burnout syndrome leading to impairment.  Being aware of these issues is imperative to prevention through self-care.


There have been many surveys conducted to assess the distress amongst mental health practitioners including psychologists, social workers, counselors, and others (See Skovholt & Trotter-Mathison, 2016;  Smith & Moss, 2009; Bride, 2007 for reviews of these studies).  The following (See Table 1) are just a few statistics that underscore the problem (along with dates of the surveys).




Table 1. Distress Among Mental Health Professionals



A survey of psychologists (1997, 2005) found that 43% reported irritability and emotional exhaustion in the year prior, 42% reported doubts about therapeutic success, and 27% reported occupational disillusionment.


A survey of counseling psychologists (1994, 2011) found that 62% identified themselves as depressed and 42% experienced suicidal ideation or behavior.  These results were similar to a previous survey done in 1985.


In a survey of state psychological association members (1989), 9% described drinking as problematic for them and 6% described it as a current problem.  A 1985 survey found 11% of psychotherapists reported problems with substance abuse.


In a 1987 survey of psychologists, 6% reported conducting therapy while under the influence of alcohol.


In a survey designed to assess PTSD symptoms in social workers who work with all types of patients who have been traumatized, it was found that 55% met at least one of the criteria, approximately one-fifth met two, and 15.2% met all three core diagnostic criteria for PTSD (compared to 7.8% in the general population). To be clear, this is PTSD symptoms in the therapists.





When discussing professional distress, it is important to distinguish among the various concepts and definitions.  Based on the literature review, there does not appear to be a well defined consensus relative to the following definitions.  Some authors hold that many of these concepts and definitions overlap significantly; whereas others define them fairly uniquely.  The following are general definitions for commonly found terms in the literature. 


In the following, we will briefly review the concepts of compassion fatigue (Figley, 1995), vicarious traumatization (McCann & Pearlman, 1990), secondary traumatic stress (Munroe et al., 1995), traumatic countertransference (Herman, 1992), burnout and impairment.


Compassion Fatigue


As discussed by Figley (2002), the very act of being compassionate and empathic extracts a cost under most circumstances.  The meaning of compassion is to “bear suffering.”  Compassion fatigue describes a syndrome resulting specifically from empathizing with people who are experiencing pain and suffering (Figley, 1995). Researchers stress that compassion fatigue should not be confused with the concept of burnout (Figley, 2002). Compassion fatigue has been defined as:


“the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other-the stress resulting from helping or wanting to help the traumatized or suffering person” (Figley, 1993, p.7). 


“reduced capacity or interest in being empathic”


“a state of tension and preoccupation with traumatized patients by re-experiencing traumatic events, avoidance/numbing or reminders, and persistent arousal (e.g., anxiety) associated with the patient” (Figley, 2002, p.1435).


Compassion fatigue can occur in any number of situations, but has been specifically identified in individuals who work with victims of traumatic events.  In the course of working with victims of traumatic events, the therapists (or other healthcare providers) themselves fall victim to “secondary traumatic stress reactions” brought on by helping or wanting to help a traumatized person.  It develops as a result of the caregiver’s exposure to patient’s experiences combined with their empathy for their patients. 


Compassion fatigue can challenge a caregiver’s ability to render effective services and maintain personal and professional relationships.  Its occurrence is often sudden and acute.  This can be contrasted with burnout (discussed below) which is thought to be a gradual wearing down of workers who feel overwhelmed by their work and incapable of affecting positive change (Figley, 1995, 2002).  While different from compassion fatigue, some authors believe that burnout may be an important risk factor or precursor to compassion fatigue (see Collins et al., 2003; Skovholt & Trotter-Mathison, 2016 for a review).  Some authors posit that compassion fatigue is related, or even identical to what has been termed secondary traumatic stress (STS) and/or vicarious trauma (VT; See Deighton, et al., 2007 for a review).  However, other authors find distinct characteristics between these syndromes. 


Secondary Traumatic Stress and Vicarious Trauma


As discussed previously, many authors believe that compassion fatigue, secondary traumatic stress, and vicarious trauma are very similar concepts but differ in their focus.  Whereas compassion fatigue is based on the idea of a syndrome resulting specifically from empathizing with people who are experiencing pain and suffering; vicarious trauma results from exposure to the client’s material, empathic engagement with these traumatized clients, and a sense of responsibility for them.  This exposure then culminates in not only cognitive, but also affective and relational changes in the therapist. 


As discussed by Figley (1995, 2002), secondary traumatic stress is defined as:


“the natural consequence of caring that happens between two people, one of whom has been initially traumatized and the other of whom is affected by the first traumatic experience”


The term “vicarious trauma” was first introduced by McCann & Pearlman (1990) who defined it as:


The concept is based in constructivist self-development theory, a developmental, interpersonal theory explicating the impact on an individual’s psychological development, adaptation and identity.


Given the lack of consensus, the terms secondary traumatic stress and vicarious trauma will be used interchangeably.  Secondary traumatic stress is the presence of PTSD-like symptoms in a caregiver, which are more likely tied to the patient’s experience than the caregivers (Collins et al., 2003).  In other words, the exposure (to the therapist) is not to an actual event as in PTSD but to knowledge about a traumatizing event being experienced by the significant other (the patient/client).  It should be noted that these effects are not necessarily a problem, but more a natural byproduct of caring for traumatized individuals. This process can become a problem if PTSD-like symptoms emerge in the therapist (compassion fatigue). 


Traumatic Countertransference


Countertransference is a concept from psychodynamic therapy involving a therapist’s emotional reaction to a client irrespective of empathy, the trauma, or suffering.  It is defined as seeing oneself in the client, overidentifying with the client, or of the therapist meeting his or her own needs through the client (Figley, 2002).  Countertransference is chronic attachment associated with the therapist’s family of origin relationships (or other historical issues) and has much less to do with empathy towards the client that causes trauma.  Relative to compassion fatigue or burnout, the concept of traumatic countertransference will not be discussed in detail in this course.




The dictionary defines burnout as “to fail, wear out, or become exhausted by making excessive demands on energy, strength, or resources.”  Burnout is an occupational hazard for human service providers. As with the other concepts, “burnout” also does not have a standard definition.  Common definitions are as follows:  


“a state of physical, emotional, and mental exhaustion caused by long term involvement in emotionally demanding situations”  (Pines & Aronson, 1988, p. 9)


“a syndrome of physical and emotional exhaustion, involving development of negative self-concept, negative job attitudes, and a loss of concern and feelings for clients” (Pines & Maslach, 1978, p. 224)


“a state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that failed to produce the expected reward” (Freudenberg, 1980, p. 13)


“a state of feeling emotionally exhausted and disconnected from other people, and lacking a sense of accomplishment from one’s work” (Maslach, 1982). 


Burnout is often related to characteristics of the work setting and demands including workload, overload of responsibility, lack of control over the quality of services provided, and interpersonal problems at the workplace.  Burnout can be distinguished from compassion fatigue in that it does not necessarily involve specific exposure to trauma and the suffering of a specific client or clients.  Researchers have noted that compassion fatigue (or STS/VT) has faster onset of symptoms; whereas burnout occurs over time.  Also, burnout can arise due to many factors including working with certain patient populations, external variables related to the work setting, the therapist’s lack of self-care, etc.




Impairment should be distinguished from the above concepts.  Certainly, compassion fatigue, STS/VT, and burnout make a professional susceptible to actual impairment.  However, these syndromes do not necessarily include impairment.  The American Counseling Association Task Force on Impaired Counselors defines Counselor Impairment as (See also the Taskforce prevention article here):


“Therapeutic impairment occurs when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client.” 


Impairment may be due to a number of different factors including, but not limited to, substance abuse or chemical dependency, mental illness, personal crisis, physical illness, or other debilitation.  The task force goes on to state that:


“Impairment in and of itself does not imply unethical behavior. Such behavior may occur as a symptom of impairment, or may occur in counselors who are not impaired.” 


They also underscore that impaired counselors must be distinguished from those are who are distressed.  A mental health professional can be undergoing significant distress while not having his or her work significantly impacted (impaired). 


Occupational Hazards and Vulnerabilities in Practice


Although often discussed separately in the literature, for the purposes of this course, we will combine burnout risk factor categories of (1) occupational hazards and (2) vulnerabilities to occupational stress.  In fact, research has demonstrated that there is an interaction between these two concepts resulting in professional distress, burnout and impairment.  As discussed by APA's Board of Professional Affairs Advisory Committee on Colleague Assistance (ACCA),


“while there are a number of approaches to understanding occupational vulnerability and impairment in psychologists, the most useful of those emphasize the interaction between the specific demands of the work and individual characteristics of each psychologist.  In other words, as psychologists, our vulnerability to occupational stress stems from the interaction between particular aspects of our work (the situation) and aspects of who we are and our current life circumstances (the person)” 


The ACCA listed some of the occupational hazards facing psychologists in professional practice and these certainly apply to all mental health and health professionals.  These can be found in Table 2. 



Table 2.  Occupational Hazards in Mental Health Practice



The stress of our role, as professionals working with people in distress


The demand and importance of clinical and professional responsibility


Varied and often quickly shifting role demands


The challenge of managing the intimate, confidential, and non-reciprocal nature of the client/therapist relationship


Isolation in the work context


Role characteristics that make mental health professionals prone to burn out


Vulnerability to vicarious traumatization from empathic engagement with traumatized clients


The changing standards in the profession


The stress related to the business of practice


The interaction between personal stresses and the demands of work


Utilizing the person of the therapist as a therapeutic tool


The heightened risk of suicide among male psychologists. 



The ACA's Task Force on counselor wellness and impairment has produced similar hazards and all of these are well documented in the literature.  These occupational hazards interact with vulnerabilities to occupational stress.  Again, these are well documented in the literature and have been summarized by the ACCA.  A general summary of these vulnerabilities can be found in Table 3 (adapted from the ACCA). 



Table 3. Vulnerability to Occupational Stress



Professional Isolation


Inadequate consultation


Poor Self-Care


Over work


A paucity of Leisure and Non-work activities


Stigma within the profession for professionals who acknowledged distress or impairment


Unrealistic self expectations, rigidity


A tendency to focus on the needs of others while neglecting our own needs and personal problems


Poor boundaries, over involvement


Imbalance in caseload/professional responsibilities (e.g. working exclusively with trauma survivors, etc.). 



The above specific occupational hazards and vulnerabilities can be generally grouped under categories of the:


Physical demands of the work

Emotional and psychological nature of the work

Personal attributes of the therapist

Systems issues related to the work


We will organize our discussion under these four general categories. 


The Physical Demands of the Work


Physical isolation. The vast majority of mental health professionals work in private settings, including solo and group practices.  This type of practice can easily result in a very high degree of physical isolation in which the practitioner basically spends the entire day in the office, seeing patient after patient.  As financial pressures mount (increased overhead with reduced reimbursements), many practitioners will not “waste time” going out of the office to take a lunch break.  A common scenario is to see patients throughout the day and take a lunch break in the office (often alone). 


Even during free time in the office when a patient is not scheduled or does not show, there are a variety of other responsibilities that “need” to be completed.  These include such things as checking email, updating charts, dictating, administrative duties, returning telephone calls, etc.  All of these activities are also generally done alone.  As the reimbursement rates for psychological services diminish, paperwork demands increase, and overhead costs go up, mental health practitioners will often justify “staying in the office” during breaks in an effort to be more cost-effective.  Instead of getting out of the office for a lunch break, the practitioner uses this time to “get some work done” while also “grabbing a snack” and preparing for the next patient. 


All of these factors promote increased physical isolation in solo practice.  With the advent and pervasive use of technology, the physical isolation is increased even further.  These days, face-to-face and telephone contact with other professionals is diminishing further and further since this is not considered a productive use of time and is “not efficient.”  For many clinicians, long gone are the days of having a professional lunch with colleagues, or meeting other professionals to discuss cases or research relative to clinical issues.  Rather, communication occurs through email, blogs, forums, texting, etc.  Even face-to-face time has been supplanted by such things as Skype, webinars and videoconferencing.  In this modern age of technology, a person can literally run his or her entire practice in almost complete physical isolation aside from doctor-patient contact (and this may be over the Internet using telehealth methods). 


As discussed by many authors, very few graduates are prepared for the unique rigors of solo practice, including the physical isolation that can occur.  In most graduate and clinical training settings, there is a high degree of contact with other colleagues and professionals including fellow students, supervisors, educational forums, etc.  Psychotherapy sessions are interspersed with a variety of other activities and interactions with other colleagues.  Psychotherapy treatment cases are analyzed in team meetings, and there is plenty of time for researching and discussing the various issues related to patient care.  This is often a very exciting and rewarding experience.  It is also in stark contrast to the physical isolation that can often occur once the student graduates and decides to pursue solo practice. 


Those clinicians who work for an agency are not exempt from physical isolation.  Even though some of the financial/business pressures of being self-employed may not be present, there are a myriad of other administrative and bureaucratic responsibilities.  Also, there may be expectations about the number of patient-contact hours that are expected by the agency along with a lack of organizational support.  As such, the potential for physical isolation in practicing psychotherapy can occur in any setting. 


Sedentary work and sensory deprivation. Aside from the potential for extreme physical isolation in the practice of psychotherapy, there is also the sedentary nature of the work.  Therapists will often sit for eight or more hours a day, in the same chair, behind the same desk, and in the same room.  If a therapist does this day after day, without attending to appropriate self-care activities, he or she is subjecting him- or herself to significant physical and environmental deprivation.  Again, in an attempt to be as cost-effective as possible, many therapists will not take the time to take a short walk, stretch, or engage in any type of exercise program in between sessions.  This type of schedule can lead to fatigue, a loss of energy, and other physical symptoms.  The isolation of the clinician’s office along with the sedentary activity can lead to a type of environmental deprivation.  The lack of physical activity and change in the environment can lead to fatigue, difficulty concentrating, mental dullness, and boredom.


Of course, the negative effects of physical inactivity and environmental deprivation are made even worse if the therapist engages in associated unhealthy behaviors such as smoking, excessive coffee, or use of other stimulants (sodas, energy drinks, etc.).  Taking a “cigarette or coffee break” may be utilized as a “reward” in between patient sessions.  This may give the therapist a physical and psychological “boost” in the short term, but over time, this will certainly exacerbate the overall negative effects of the physical isolation and sedentary nature of the work. 


The various elements of physical isolation may not be as significant for mental health professionals who work in larger settings such as multi-disciplinary healthcare centers, hospitals, etc.  In these settings, there is often the ability to interact with other professionals in between patients, team conferences, and facilities where “breaks” can be easily taken (e.g. a hospital cafeteria, etc.).  Even so, as we will discuss, mental health practitioners working in agency settings experience their own sets of occupational hazards and in research they often express more distress than their counterparts in solo practice. 


The Emotional and Psychological Demand of The Work


Probably even more significant than the physical demands of the work are the emotional and psychological pressures.  In the emotional and psychological arenas, the following are some of the factors that make mental health professionals vulnerable to distress.


One-way intimacy.  The psychotherapy profession primarily consists of working long hours in physical and emotional isolation.  The nature of work necessarily involves working with individuals who are in crisis and psychological/physical pain.  The mental health therapist is expected to offer these individuals support, empathy, interpretation, explanation, direction, or advice.  Given this situation, many clinicians feel emotionally isolated.  The very nature of the psychotherapeutic relationship includes an exclusive focus on the client/patient’s psychological world in which the purpose is certainly not to meet the clinician’s emotional needs.  As such, the therapist will purposely limit self-disclosure in an appropriate fashion and provide treatment in the best interests of the patient.  Even the active treatments such as cognitive behavioral therapy do not involve emotional expression on the part of the clinician that is related to him or her versus the patient.  The very nature of the psychotherapy relationship makes the clinician vulnerable to emotional isolation and “emotional depletion.” 


Confidentiality.  One of the most important elements of the psychotherapeutic relationship is confidentiality. While the therapist is the repository of significant knowledge about the distress of his or her patients (along with the emotional reactions to the information), this is not information that can be shared with one’s usual support networks (e.g. family, close friends).  In fact, it cannot be shared at all outside of a peer consulting and/or supervisory relationship.  In most cases, not only is the clinician managing (treating) the emotional needs (issues) of the patient in the psychotherapeutic relationship, he or she is generally not able to share his or her emotional response to the situations with others.  Many clinicians rely on collegial and/or supervisory relationships to help with these issues.  However, many clinicians in private and solo practices do not prioritize these types of peer/collegial/supervisory relationships nor do they make time to develop and utilize them.  They are essentially dealing with the emotional management of their patients in isolation.  It is certainly inappropriate to share information or emotional issues related to patient care with family and friends.  Therefore, they are left with no resources relative to these issues. 


Evaluate-Treat-Discharge-Repeat. Related to the emotional depletion is the “endless cycle of introduction to new patients, conducting psychotherapy, and finally terminating the relationship.”  The clinician is expected to connect and disconnect with patients on a regular basis. In a case where the clinician has valued working with a patient and the outcome was successful, there may still be a mild grief-like reaction at termination.  Alternatively, in the vast majority of cases, even this process does not occur.  Rather, patients will begin therapy and either drop out, terminate prematurely (for a variety of reasons of which the therapist is unaware), or decide to terminate due to extra-treatment variables (lack of finances, etc.).  This premature termination situation is likely to be even more stressful for the therapist.  If a clinician has invested a significant amount of time and effort in treating a patient, anything short of a successful conclusion to the intervention will be at least somewhat stressful to the therapist.  We all understand that the process of therapy is not to meet the needs of the clinician and that one is paid for the delivery of services; however, this does not preclude an appropriate emotional response when it does not go as planned or falls short of the therapist’s expectation for outcome.   Experiencing this cycle over and over again can result in emotional depletion.  In addition, all of this is occurring within the context of emotional isolation. 


Attributes of the patient.  Another stressful aspect of the nature of psychotherapy is certain patient attributes.  Anyone in the mental health business knows that working with certain personality disorders (e.g. borderline) can be a very challenging and stressful professional endeavor.  The specifics of the stress related to working with certain personality types is acknowledged and will not be discussed in detail here. 


Aside from seeing patients who are typically distressed and in crises, there are the extreme cases of the suicidal patient and those who actually threaten the therapist.  The probability of a mental health therapist having a patient threaten, attempt, or commit suicide is fairly high over the course of one’s career.


More than 50% of psychiatrists and 20% of psychologists report having lost at least one patient to suicide


In at least one study, 71% of mental health counselors in practice reported having had at least one client attempt suicide


In the same study, 28% had at least one client commit suicide


Consistent with common sense, research has indicated that therapists will experience fairly significant psychological distress in response to a client’s suicide.  Aside from the grief associated with the loss, multiple factors also contribute to the therapist’s distress including:  the therapist ruminating over what could have been done to prevent the suicide, treatment decision-making that may have inadvertently contributed to the successful suicide, guilt associated with the therapist’s belief that warning signs were ignored, negative reactions and lack of support from the institution in which the therapist is employed, and the fear of legal action related to the suicide. 


Another area of significant stress related to patient behavior is that of aggressiveness or threats towards the clinician.  Statistically, approximately 50% of all psychotherapists will be threatened, harassed, or physically attacked by a patient at some point in their careers.  Aside from these extremes, aggressive patient behavior can also manifest itself in a variety of other ways including unwanted phone calls to the home or office, verbal threats during the course of a psychotherapy session and elsewhere, threats against family and friends, destruction of property, and stalking. 


Working with trauma survivors.  Mental health professionals are frequently involved in treating patients who are survivors of various types of trauma including childhood abuse, domestic violence, violent crime, disasters, as well as war and terrorism.  It has become increasingly apparent that the psychological effects of the traumatic events extend beyond the specific individual affected.  Secondary traumatic stress (STS), as defined previously, is viewed as an occupational hazard of providing direct services to traumatized populations.  The following discussion is based on several review articles including Bride, 2007; Collins & Long, 2003; Deighton et. al., 2007; and Pross, 2006. 


In the United States, the lifetime prevalence of exposure to traumatic events ranges from 40% to 81%.  Given these statistics, exposure to traumatic events is certainly high in the general  population. Not surprisingly, it is even higher in subpopulations for whom mental health professionals are likely to provide services.  For example, 84% of psychiatric inpatients have experienced at least one traumatic event and 45% have experienced three such events or more.  Also, between 82% and 94% of outpatient mental health clients report a history of exposure to traumatic events.  In this group, 31-42% fulfills the criteria for a post-traumatic stress disorder (PTSD).  Among treatment-seeking substance abusers, 60-90% have a history of sexual or physical abuse and 30-50% meet the criteria for a diagnosis of PTSD. 


Just these overview statistics underscore the fact that mental health professionals are very frequently confronted with patients who have been the victims of traumatic events at some point in their lives.  Mental health professionals who work with trauma victims are at increased risk for vicarious trauma or compassion fatigue.  In essence, what the practitioner hears from clients can impact their beliefs, can become too much to manage, and can cause overwhelming feelings and result in PTSD-like symptoms.  As discussed by Deighton et al. (2007),


“although working through the traumatic events experienced by a sufferer of PTSD seemed to be beneficial to the client, psychotherapy work with torture victims is potentially harmful to the therapist.  A growing body of literature suggests that being exposed to described traumatic events while treating can lead to a form of traumatization in therapists, manifested in symptoms similar to those of PTSD, including intrusive and avoidant symptoms, physiological arousal, and feelings of helplessness and isolation” (p. 64). 


In a study completed by Bride (2007), these effects were documented empirically.  In the study, a survey was sent to 600 master’s-level social workers designed to assess the prevalence of secondary traumatic stress.  These surveys included a collection of demographic information as well as completion of the Secondary Traumatic Stress Scale (STSS).  The Secondary Traumatic Stress Scale is a 17-item, self-report instrument designed to assess the frequency of intrusion, avoidance, and arousal symptoms associated with STS resulting from working with traumatized populations.  Each item on the STSS corresponds to one of the 17 PTSD symptoms (only Criteria B, C and D are included) as delineated in the DSM-IV-TR.  An overview of the DSM IV criteria for PTSD as expressed in the STSS can be found in Table 4. 



Table 4. PTSD Symptoms as Expressed on the STSS



Criterion B – Intrusive symptoms


Intrusive thoughts about clients

Disturbing dreams about clients

Sense of reliving clients’ trauma

Cued psychological distress

Cured physiological reaction


Criterion C – Avoidance symptoms


Avoidance of clients

Avoidance of people, places, things

Inability to recall client information

Diminished activity level

Detachment from others

Emotional numbing

Foreshortened future


Criterion D – Arousal symptoms


Difficulty sleeping


Difficulty concentrating


Easily Startled



Relative to the results, the authors discussed that “it is encouraging to note that despite working with traumatized clients nearly half (45%) of respondents failed to meet any of the diagnostic criteria other than exposure.”  However, 55% met at least one, approximately one-fifth met two, and 15.2% met all three core diagnostic criteria for PTSD.  The frequency of diagnostic criteria of PTSD due to secondary exposure related to practice with traumatized populations can be found in Table 5.  



Table 5. Frequencies of PTSD Symptoms



Criteria Met








Criterion B – Intrusive symptoms


Criterion C – Avoidance symptoms


Criterion D – Arousal symptoms


Intrusion Avoidance (B C)


Intrusion Arousal (B D)


Avoidance Arousal (C D)


Intrusion Avoidance Arousal (B C D)




















Adapted from Bride (2007, p. 67)



The author discussed that the questionnaire (STSS) is designed to assess only criteria B, C, and D of PTSD.  It does not assess criteria A, (exposure and response), criteria E (duration), and criteria F (impairment).  Criteria B, C, and D are considered to be the core symptoms of PTSD.  In the study, 97.8% of the respondents indicated that their client population is at least mildly traumatized and 81.7% reported a moderately to very severely traumatized client population.  As the author discusses beginning on page 67 “clearly, social workers are indirectly exposed to trauma as a result of their work with clients and, thus, may be at risk for experiencing STS symptoms.”  Regarding individual symptoms, the most often reported symptoms were intrusive thoughts, avoidance of reminders of clients and numbing responses (See Table 5).  The author points out that it is encouraging that nearly half (45%) did not meet any of the three core criteria for PTSD.  The author discusses that “the experience of STS is believed to be one reason why many human services professionals, including social workers, leave the field prematurely (page 68).  Not attending to symptoms of STS in professional helpers can lead to short and long term emotional and physical disorders, strains on interpersonal relationships, substance abuse, and burnout. 


“Working through” as a treatment technique.  As discussed by Deighton et al. (2007), the prevailing opinion amongst psychotherapists treating traumatized individuals is that “working through” the traumatic event is beneficial to the sufferer.  However, not all therapists advocate or use this approach.  The most direct form of “working through” includes confronting the client with stimuli related to the traumatic events.  This most commonly includes imagining, remembering, and discussing the various aspects of the incidents.  The working through process is often combined with a cognitive behavioral therapy approach with the goal of integrating the traumatic events into the client’s “life story” leading to a restructuring of dysfunctional beliefs and attitudes.  These concepts are also found in other approaches to the treatment of trauma.  As quoted earlier from the article, the authors discussed the fact that although working through the traumatic events is beneficial to the client, it may lead to a form of traumatization in the therapist.  These authors investigated factors affecting burnout and compassion fatigue in psychotherapists treating torture victims.  In brief summary, the study investigated the level of a therapist’s “advocacy” for the working through process and how this was related to compassion fatigue and burnout.  The researchers found that the degree to which a therapist works through traumatic events with a client and advocates this treatment approach are important variables related to the risk of symptoms (in the therapist).  If a therapist advocates the working through process as part of the therapy, but does not achieve it, this seems to put the clinician at more risk for STS as compared to those who neither advocate working through nor practice it.  This former group is also at more risk than those therapists who advocate the working through process and are successful in achieving it.  As discussed by the authors (page 71) ”these findings indicate that it is not the exposure itself so much as what the therapist does in the face of the exposure, which represents a risk factor for work related symptoms.” 


Personal Attributes of the Therapist


Another area that may represent a hazard or vulnerability for compassion fatigue, STS/VT and burnout (clinician distress) includes the personality and history of the therapist.  As discussed by Saakvitne (ACCA document) the mental health therapist draws upon his or her own unique resources and knowledge, shaped by personal history, life experiences, personality, etc.  These unique personal characteristics represent both strengths and potential areas of vulnerability.  As discussed previously, these factors interact with aspects of the work situation and setting.  For instance, one might look at the reasons why an individual chose to become a mental health professional.  Some of the reasons put forth by various authors, albeit slightly anecdotal, include the following: 


Curiosity about their own personalities


Hoping to find solutions to personal problems or resolution of underlying conflicts


A desire to relieve emotional distress


A tendency to be drawn to the intimate and counters of psychotherapy out of a desire to combat loneliness


The chance to exercise and influence over patients or vicariously live through them


Wanting to make a difference, but with a “god-like” position of control possibly including arrogance and grandiosity


The unspoken belief that their caring has special curative powers


A personal history of being born into or assigned a role of caretaker at an early age in their families of origin



Freudenberger (1975) published one of the first articles postulating some issues related to burnout.  In the non-empirical article, he poses the question, “What are the different types of personality most prone to burnout…..?”.  He discusses interesting possibilities that are certainly worth keeping in mind. The following personality styles are adapted and expanded from that article:


The dedicated and committed worker burnout.  Freudenberger relates these features to those that work in such settings as free clinics, hot lines, crisis intervention centers, runaway houses, and other similar settings (e.g. non-profits, etc.).  Even so, this could clearly apply to any setting or self-imposed clinician-focus that includes a special passion and involvement in work that goes beyond simply making a living doing psychotherapy.  This might include making less money to work for a certain patient group, long hours, etc.  He summarized it as clinicians who are seeking to respond to a need in the community.  The therapists seek to help those in the community because they see themselves as dedicated in some ways and “enlightened people in other ways” (e.g. socially, politically, spiritually, or intellectually).  Some therapists are involved in these pursuits in order to gain enlightenment themselves – looking for further personal identity or a shift in life style.  They are there first to be of help but also because they are struggling with their own personal values system. These therapists are dedicated through their work involvement and “would rather put up than shut up.” 


Freudenberger posits that it is exactly because these therapists view themselves as dedicated and committed individuals that they are more vulnerable to gradual burnout, if they are not careful. As he states, “The committed worker tends to take on too much, for too long, and too intensely” (p. 74).  Coming from within the therapist, there is the pressure to accomplish and succeed.  This is combined with the external pressures of the needs and demands of the patient population.  In the agency setting, these two pressures can be combined with a third, those of the agency or institution.  Freudenberger terms this situation a “three-way squeeze” which can result in a “three-level burnout”.  The therapist is “at the mercy of his own needs, the needs of the population seeking help, and the administrator’s needs.” At this point, the dedicated therapist’s guilt, feelings that s/he is super-healer, and desire to be of genuine help, pushes the person to work even harder.   This starts a cycle of working harder, being more frustrated, increased exhaustion, etc., that leads down the slippery slope to burnout. Freudenberger discusses the differences between commitment, over-commitment, involvement, dedication, and over-dedication.  There is nothing wrong with the commitment, involvement and dedication.  The vulnerabilities arise with over-commitment and over-dedication.   


This concept of a three-way squeeze leading to a three-level burnout might easily be generalized to other settings.  One example is the therapist in private practice who has chosen to specialize in borderline personality disorders. This is a difficult and challenging patient population in which the goals of treatment are most often management and then “cure”. Clearly, a three-way squeeze might occur including the therapist’s need/desire to help, the almost endless and ubiquitous demands from the patients, and the limited resources to provide the necessary treatment (e.g. lack of financial resources for long-term treatment, policies of the agency/institute, other systems issues). Any therapist who specializes in a particularly challenging patient population (e.g. personality disorders, abuse cases, end of life, pediatric oncology, just to name a few) must pay particular attention to self-care.  


Over-commitment with sub-satisfactory outside life.  According to Freudenberg, another candidate for burnout is the personality type who uses the work (clinic, center, office) as a substitute for a social life. The atmosphere and satisfaction from some aspects of one’s work can be so seductive that the therapist finds him- or herself spending even free time in the work setting.  Interestingly, since Freudenberg’s article in 1975, through the development of modern communications, one can now spend free time “at work” while not being physically there. As human beings, therapists need an outside life that is separate and distinct from work.


The authoritarian burnout.  Freudenberg develops the idea of the authoritarian as the type of individual that needs to be in control of everything.  Freudendberg discusses this in terms of an agency setting in which this individual needs to be in control and feels s/he can do the job better than anyone else.  This individual will overextend due to a “deep personality need to control”, but will burnout in the process. The personality type – the need to be in control – might be generalized beyond the agency setting.  Any therapist that needs to control everything, and thinks that s/he can do a job better than anyone else, will not be able to delegate and will try to control even the minutia of psychotherapy practice.


The over-involved professional. The committed professional needs to be aware of his or her tendency to over-identify with patients. In this process, there is the risk of “losing” oneself. As discussed by Freudenberg, “As professionals, we also need to convey to others our feelings of wanting to be needed above and beyond the skills for which we were trained and which we are qualified to perform.”  The over-involved professional may be “forced” to performed extra duties (either self-imposed or by administration), put in way too many hours, etc.  This can occur in any work setting including an agency, institution, and private practice. 



It is beyond the scope of this course to discuss all the possible psychological make-ups of the clinician that can impact and influence one’s vulnerability to work related distress.  However, it is important to have insights into one’s own motives for entering the field and for continued involvement in it. In addition to our personal histories, current life circumstances can also impact vulnerability to occupational distress.  Ongoing stressful life events can impact a clinician’s ability to provide quality care, and any stressful event in the clinician’s life has the potential to impact his or her ability to function professionally.  Examples include such things as financial issues, family problems, divorce, pregnancy, and death of a loved one, among other things. 


Systems Issues


Work setting. Virtually every study investigating work setting and stress among mental health practitioners has demonstrated that those employed in institutional and HMO settings experience more distress and burnout symptoms than those in private practice.  However, mental health professionals in private practice find patient behaviors and financial concerns more distressful than their colleagues in institutional settings. 


The impact of work setting was directly researched by Rupert & Morgan (2005).  They reviewed the consistent finding related to work setting discussed above.  They state that the difference has been attributed to several possible factors:  (1) that independent practitioners may have greater control over their work activities, (2) they may have less paperwork and other bureaucratic responsibilities, and (3) they may see less disturbed clients.  These authors sought to investigate these issues directly since the private practice environment has changed dramatically over the past several years.  The research included a survey (almost 600) sent to three groups: solo practice, group practice, and agency practice.  The survey addressed such things as general information about years of experience, total hours worked, attitudes towards workload, and satisfaction with income.  The details of the study will not be reviewed here.  The authors state that it was the largest national survey to examine burnout among professional psychologists since a previous study completed in 1988. 


The authors discussed the fact that even given the negative impact of managed care on the practice of psychology, their results indicated that the overall levels of burnout reported in the sample were similar to those found in the 1988 study.  They concluded that “although burnout remains a serious concern, it is encouraging that there are no indications from our data that levels of burnout have increased markedly in recent years” (page 548).  The researchers used the Maslach Burnout Inventory (MBI) to assess levels of burnout.  The MBI consists of subscales of emotional exhaustion, depersonalization of clients, and personal accomplishment. It was found that, of the three components of burnout, psychologists appear to be at greatest risk for emotional exhaustion.  They concluded that many psychologists experience feelings of exhaustion related to their work but, for most, this does not develop into a full burnout syndrome. 


Consistent with previous research, their results also indicated the same differences across work settings relative to burnout.  They concluded that, for the most part, independent practitioners fair better on indices of burnout than their agency colleagues.  Solo practitioners reported less emotional exhaustion than agency respondents and both solo and group practitioners experienced a greater sense of personal accomplishment than agency respondents.  They did find that having a higher percentage of direct pay clients was associated with lower levels of emotional exhaustion and depersonalization of clients and higher levels of personal accomplishment (in the solo and group practitioner groups).  They surmise that direct pay clients pose fewer difficulties and offer more rewards in a number of aspects including less paperwork, higher functioning clients, and more economic rewards.  In addition, solo and group private practitioners reported dealing with negative client behaviors less frequency than did agency respondents.  Lastly, they found that “there was one somewhat negative factor in which independent practice respondents scored higher than agency respondents: both solo and group practitioners reported higher levels of over-involvement with clients (e.g. thinking about clients outside of work, talking frequently on the phone, feeling responsible for the client)”  (p. 550).  Over-involvement was associated with higher levels of emotional exhaustion and depersonalization.  They concluded that burnout is a multi-determined phenomenon that cannot be predicted on the basis of work related variables alone. 


It might be concluded that each work setting comes with its own unique set of occupational hazards related to stress.  In the private practice setting, major stressors include managed care, time pressures, economic uncertainty, caseload uncertainty, business related duties, and excessive workload (Norcross et al., 2000).  Independent practitioners often complain of frustrations with insurance companies and third party payers along with unrealistic demands from patients to deal with these “systems” issues. In agency settings, stressors might include such things as bureaucratic and administrative hassles, being overloaded with tasks, inadequate resources, lower financial reward relative to independent practice, and dealing with a more disturbed patient population. 


Managed care.  Whether carefully documented in the research or not, a common complaint among solo practitioners is the influence of managed care on the quality of practice.  Aside from direct pay clients, which are becoming fewer and farther in between given the current economic environment, most practitioners in solo practice must deal with managed care issues.  This involves such things as accepting reduced levels of pay, mountains of paperwork related to obtaining authorization to treat, and ongoing interactions with Utilization Review in order to continue with the proposed treatment plan.  Of course, all of the time involved in obtaining approval for treatment, and justifying one’s treatment approach, is not reimbursable.  This is being done in the face of diminishing reimbursement for actual treatment time.  As these pressures mount, the clinician may be vulnerable to feelings of resentment, especially when faced with a demanding client.  The harbinger of insidious onset of burnout is heralded by feeling like “they are not paying me enough to do this job.”  This issue may not be significantly documented in the empirical research, but it is certainly very prevalent in the various blogs and discussion forums among mental health professionals.  This is evident in the opening example of the neuroscientist who was thinking about going into the mental health profession.


The impact of managed care on private practice was empirically investigated by Rupert and Baird (2004).  However, this data is now over a decade old since it was actually gathered in 2001.  Some interesting patterns emerged relative to the current discussion.  The study involved sending a survey out to psychologists in practice that was identical to one sent out in 1996.  This allowed for an assessment of psychologists’ status relative to managed care as of 2004 (actually 2001 when the data was collected) and being able to compare it to 1996 findings.  Both the 1996 and 2001 surveys included a random sample of 1200 psychologists.  Without going into the details of the various assessment instruments, the following results were found. 


In both samples, the most highly ranked sources of stress related to managed care included: external constraints on services, managed care paperwork, managed care reimbursement rates, and excessive paperwork. The rating for sources of satisfaction remained stable and included helping trouble individuals and being socially useful. 


As part of the study, the authors compare low managed care (LMC) practitioners (less than 10% of one’s practice) and high managed care (HMC) practitioners (80% or more).  These groups differed on a number of work-related variables.  The HMC reported working more total hours per week, more hours doing therapy, and less hours obtaining supervision.  In addition, the HMC group experienced more work-related stress than the LMC group.  The HMC group had higher overall stress ratings and higher specific stress items: excessive paperwork, physical exhaustion, lack of gratitude from clients, excessive workload, external constraints on services, and managed care paperwork.  The HMC group also scored higher on the Negative Clientele subscale of the Psychologist Burnout Inventory and the Emotional Exhaustion scale of the MBI.


The authors also noted that the HMC respondents show signs of being less satisfied with their work relative to the LMC group. They rated themselves as less satisfied with their income, salary as less fair, and indicated they thought about leaving the practice of psychology more frequently.     


The pattern of results is very applicable to the current discussion of professional distress and burnout.  The most recent survey was conducted in 2001, over 10 years ago.  I think most would agree that the impact and pervasiveness of managed care has continued over the past decade and is now essentially ubiquitous.  If this assumption is correct, then all of the findings relative to the high managed care group in the 2001 survey might generalize to most mental health practitioners.  If one looks at the pattern of that group’s responses, they are consistent with many of the hazards and vulnerabilities for burnout.


The Development of Compassion Fatigue and Burnout


We have reviewed the various occupational hazards and vulnerabilities relative to mental health professionals developing distress (of all types).  In this section we will review the theoretical models associated with onset of these conditions.  In general, symptoms of compassion fatigue (Secondary Traumatic Stress; STS) can be found in Table 6. You can also print a copy here.




Table 6. Impact of STS on Professional Functioning



Performance of Job Tasks












Decrease in quality


Decrease in quantity


Low motivation


Avoidance of job tasks


Increase in mistakes


Setting perfectionistic standards


Obsession about details



Decrease in confidence


Loss of interest




Negative attitude






Lack of appreciation




Feelings of incompleteness


Withdrawal from colleagues




Decrease in quality of relationships


Poor communication


Subsume own needs


Staff conflicts











Faulty judgment










Frequent job changes






Adapted from Yassen, J. (1995). Compassion Fatigue (p. 191). New York: Brunner/Mazel.



Compassion Fatigue


In this section, we will review etiologic influences that result in compassion fatigue.  As discussed previously, compassion fatigue (for the purposes of this discussion also referred to as secondary traumatic stress and vicarious trauma) can be differentiated from burnout.  Compassion fatigue has a faster onset of symptoms and a faster recovery when appropriately addressed.  Compassion fatigue is associated with a sense of helplessness and confusion, along with a greater sense of isolation from supporters.  Compassion fatigue is highly treatable once it is recognized and appropriately addressed (see Figley, 2002 for a review).  Figley published the first book on compassion fatigue in 1995.  Since that time, there has been more research and attention to the “cost” of caring and the relationship between the role of empathy and previous traumatic experiences.  Empathy and emotional energy are the driving force in effectively working with individuals who are suffering in general.  These qualities are essential in terms of establishing and maintaining an effective therapeutic alliance and delivering effective services.  However, there are “costs” to the clinician related to being compassionate and empathic.  Figley (2002) identified ten variables that form a causal model that predicts compassion fatigue.  Having an understanding of these variables can help prevent its occurrence (as well as identify it in others). 


Empathic ability.  Empathic ability is the aptitude of the psychotherapist for noticing the pain of others.  The model suggests that without empathy there will be little if any compassion stress and no compassion fatigue.  However, there will also be little if any empathic response to the suffering clients.  The ability to empathize is a cornerstone to helping others while also making one vulnerable to the cost of caring.  Low empathic ability may protect against compassion fatigue but also make one ineffective as a therapist. 


Empathic concern. Empathic concern is the motivation to respond to people in need.  The ability to be empathic as described above is insufficient unless there is a motivation to help others who require the services of a mental health professional. 


Exposure to the client. “Exposure to the client” is experiencing the emotional energy of the suffering of the client’s through direct exposure.  Direct exposure to the suffering of the client is certainly imperative for successful psychotherapy treatment outcomes.  However, the cost of direct exposure to the suffering of others is high relative to the risk of compassion fatigue and burnout.  


Empathic response. Empathic response is the extent to which the psychotherapist makes an effort to reduce the suffering of the sufferer through empathic understanding.  In order to achieve insight into the psychological state of the client, the psychotherapist must experience the perspective of the patient at least on some level.  In doing so, the clinician might experience the various negative psychological states experienced by the patient.  Again, this constitutes both the benefit and cost of a powerful therapeutic relationship and response. 


Compassion stress. Compassion stress is the residue of emotional energy from the empathic response to the client and the ongoing demand for action to relieve the suffering of a client.  This ongoing stress can affect the clinician both physically and emotionally.  Unless compassion stress is controlled, it facilitates the emergence of compassion fatigue.  As discussed by Figley (2002), there are two major sets of coping actions that can help control compassion stress. 


Sense of achievement.  Sense of achievement is one factor that lowers or prevents compassion stress and is the extent to which the clinician is satisfied with his or her efforts to help the patient.  If the practitioner has a sense of achievement regarding delivery of services, then compassion fatigue will be attenuated.  Sense of achievement includes a rational effort to recognize where the psychotherapist’s responsibilities end and the client responsibilities begin.


Disengagement.  Disengagement is the other factor that lowers or prevents compassion stress.  This is the extent to which the clinician can distance him or herself from the ongoing misery of the patient between sessions in which services are delivered.  This may involve a conscious effort on the part of the clinician to recognize that he or she must “let go” of various issues in between sessions.  It also involves the clinician understanding the importance of self-care and to implement a deliberate program of self-care. 


Prolonged exposure.  Prolonged exposure is the ongoing sense of responsibility for the care of suffering, over a protracted period of time.  It is important to take breaks (brief and longer) in order to prevent prolonged exposure.  These breaks can be viewed as a respite from being compassionate and empathic toward patients as well as from being a professional service provider. 


Traumatic recollections. Traumatic recollections are memories that trigger the symptoms of PTSD and associated reactions such as depression and anxiety.  These traumatic recollections are experienced by the clinician and may be memories from experiences with other, demanding or threatening clients, or those who were especially sad or suffering.  When these memories are recalled, they cause an emotional reaction. 


Life disruption. Life disruption is the unexpected changes in schedule, routine, and managing life responsibilities that demand attention (e.g. illness, social status, changes in lifestyle, etc.)  These disruptions usually cause a certain, but tolerable level of distress.  However, when combined with the other seven factors, these disruptions can increase the chance of developing compassion fatigue. 




As discussed previously, burnout can be distinguished from compassion fatigue in many ways.  Compassion fatigue results from influence inherent in the therapist-patient relationship; whereas, burnout can be the result of many factors.  Burnout is a “state of physical, emotional, and mental exhaustion caused by long term involvement in emotionally demanding situations” (Pines & Aronson, 1988, p. 9).  It does not necessarily include specific exposure to trauma and suffering of a specific client (as in compassion fatigue).  Burnout has a slow onset of symptoms and a slower recovery, once identified.  Burnout symptoms are categorized as can be found in Table 7.    




Table 7. Burnout



Physical symptoms

physical exhaustion

physical difficulties

somatic problems

rapid exhaustion


Emotional symptoms







sense of helplessness

feeling of hopelessness

a feeling of failure

tendency to blame one’s self


Behavioral symptoms






avoidance of clients

substance abuse


Work related symptoms

quitting the job

poor work performance



constant seeking avoidance of work



work as a heavy burden


Interpersonal symptoms

perfunctory communication

inability to concentrate

social withdrawal

lack of a sense of humor


poor patient interaction

impersonal, uncaring, and cynical attitude towards clients




Various assessments of burnout have been developed.  One simple checklist is the Stress Reaction Inventory provided by the ACA Resources (click here for a copy).  One of the most frequently used is the Professional Quality of Life (ProQOL).  The ProQOL is the most commonly used measure of the negative and positive effects of helping others who experience suffering and trauma.  The measure has been in use since 1995 and Version 5 is currently available.  The instrument consists of 30 items that are scored from 0 (never) to 5 (very often).  The instrument can be self-scored and yields subscores for compassion satisfaction, burnout, and compassion fatigue/secondary trauma.  The following are descriptions of each scale (and these are also found on the assessment; See Table 8): 



Table 8.  Subscales of the ProQOL and Definitions



Compassion Satisfaction


Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job.


The average score is 37 (SD 7; alpha scale reliability .87). About 25% of people score higher than 41 and about 25% of people score below 32. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 32, you may either find problems with your job, or there may be some other reason—for example, you might derive your satisfaction from activities other than your job.





Most people have an intuitive idea of what burnout is. From the research perspective, burnout is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout.


The average score on the burnout scale is 23 (SD 6.0; alpha scale reliability .72). About 25% of people score above 28 and about 25% of people score below 19. If your score is below 19, this probably reflects positive feelings about your ability to be effective in your work. If you score above 28, you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.



Compassion Fatigue/Secondary Trauma


Compassion fatigue (CF), also called secondary trauma (STS), and related to Vicarious Trauma (VT) is about your work-related, secondary exposure to extremely stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called VT. If your work puts you directly in the path of danger, such as being a soldier or humanitarian aide worker, this is not secondary exposure; your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your work, such as in an emergency room or working with child protective services, this is secondary exposure. The symptoms of CF/STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event.


The average score on this scale is 13 (SD 6; alpha scale reliability .80). About 25% of people score below 8 and about 25% of people score above 17. If your score is above 17, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care professional.



As part of the course, complete the ProQOL assessment at this time (click here for a copy).  We have already discussed compassion fatigue, vicarious traumatization, and burnout.  However, we have not discussed the concept of compassion satisfaction.  Research has demonstrated that neither vicarious traumatization or compassion fatigue are synonyms of PTSD or of secondary trauma stress.  Individuals can experience the negative effects of secondary exposure without developing a psychological disorder such as PTSD.  Compassion fatigue is not a diagnosis.  As discussed in the literature review on the website (ProQOL Theory), compassion satisfaction and compassion fatigue can be thought of in the simplest terms as the positive aspects of helping or the “good stuff” (CS) and the negative aspects of helping, or the “bad stuff” (CF).  The full compassion satisfaction-compassion fatigue theory includes three key environments: work environment, client-patient environment, and personal environment.  A diagram of the model is as follows:




 Figure. Full Compassion Satisfaction – Compassion Fatigue Model


It should be noted, and as discussed previously, in some models, compassion fatigue leads to burnout and/or secondary trauma.  In other models, burnout is seen as a separate entity. 


A Conceptual Model of Burnout


We have previously reviewed a conceptual model of compassion fatigue.  Burnout appears to be somewhat of a separate entity as discussed in the literature review.  The literature has developed an underlying consensus about three core dimensions of the burnout experience (Maslach, 1982, 1993; Maslach and Goldberg, 1998).  According to this model, burnout is a type of prolonged response to chronic emotional and interpersonal stressors on the job.  It is an individual stress experience embedded in a context of complex social relationships, and it involves the person’s conception of both self and others.  Burnout is defined as a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment.  The model is described by Maslach as well as Maslach & Goldberg (1998). 


Emotional exhaustion refers to feelings of being emotionally overextended and depleted of one’s emotional resources.  The major sources of this exhaustion are work overload and personal conflict at work.  People feel drained and used up, without any source of replenishment.  They lack enough energy to face another day or another person in need.  The emotional/exhaustion component represents the basic stress dimension of burnout. 


Depersonalization refers to a negative, callous, or excessively detached response to other people, which often includes a loss of idealism.  It usually develops in response to the overload of emotional exhaustion, and is self-protective at first-an emotional buffer of detached concern.  But the risk is that the detachment can turn into dehumanization.  The depersonalization component represents the interpersonal dimension of burnout. 


Reduced personal accomplishment refers to a decline in feelings of confidence and productivity at work.  This lowered sense of self efficacy has been linked to depression and an inability to cope with the demands of the job, and it can be exacerbated by a lack of social support and of opportunities to develop professionally.  Individuals experience a growing sense of inadequacy about their ability to help clients and this may result in a self-imposed verdict of failure.  The personal accomplishment component represents the self-evaluation dimension of burn out. 


Preventing Burnout: Self-Care


One of the most important methods for preventing burnout and compassion fatigue is to incorporate self-care activities into your daily routine.  This includes both psychological and physical self-care.  Most mental health practitioners are very adept at advising their clients to adopt a healthy lifestyle to combat various stressful issues but may not do a great job at doing it themselves (the old adage, “do as I say, not as I do” is not a recipe for therapist self-care).  This includes such things as decreasing and eliminating negative health habits (smoking, alcohol, etc.), engaging in a regular exercise program, meditation techniques, time management, developing a balanced diet, getting adequate sleep, etc.  All of these factors have been found to improve overall mood and physical status (e.g. energy, stamina, etc.).  For a Self-Care Assessment Worksheet, click here. The following are just some ideas about self-care.  Many possibilities related to the need for self-care, and associated resources, can be found elsewhere (American Psychological Association Self-Care ResourcesAmerican Counseling Association Taskforce on Counselor Awareness and Impairment, just to list a couple). 


Self-analysis. Probably the most obvious self-care method, and the one most frequently missed, is being aware of the insidious onset of burnout in the first place.  Prevention of burnout is much easier than treating it after it has occurred.  Self-analysis might begin with something as simple as looking at the results from the ProQOL assessment.  Beyond that, taking an objective look at symptoms presented in the various Tables and checklists previously reviewed that might indicate burnout.  An excellent method to “get a second opinion” is to ask family, friends and colleagues about how they think you are doing. 


Healthy and relaxed lifestyle.  Research has consistently demonstrated that good health and physical fitness can help protect against stress and burnout.  Thus, burnout prevention strategies always include suggestions for nutrition, exercise, reduction of unhealthy habits, etc. Helping to promote a “relaxed” lifestyle might include many different things such as relaxation exercises, meditation, cognitive restructuring, etc.  Another example might be rearranging and addressing financial issues.  For instance, if one is used to a certain lifestyle and mental health practice incomes are decreasing, there are only two choices: Either work even harder and more hours to make enough money to maintain that lifestyle or modify the lifestyle so that it does not require so much money to maintain.  Depending on the situation, the clinician may need to think creatively about how to develop a healthy and relaxed lifestyle.  


Leisure activities.  Self-care also involves developing leisure activities that have nothing to do with the practice of psychotherapy.  These can be daily activities such as a hobby or other pursuit as well as more lengthy activities such as a vacation.  This might include such things as planning a vacation that is not associated with a professional conference.  Appropriate and quality “time away” also includes being un-tethered from electronic devices that connect you to the office.  In this age of modern technology, we are, unfortunately, “always available” and this is both a curse and a blessing.  Time away from the office during a vacation does not have the same restorative properties if you are still available by phone, e-mail, text, etc.  Even though contact with your office may be infrequent, simply the anticipation that you “may be contacted” causes a low level of background stress (anticipatory).  As such, these electronic devices prevent the practitioner from ever truly being “off work.”  This seeks to thwart the purpose of leisure, which is to create a meaningful and balanced life.  One of my favorite ways to “get away” is going to the mountains where there is no cell phone reception or Internet.  Even though the temptation to “connect” may occasionally arise, it is simply not possible.  After a few days, I don’t even think about connecting with anyone aside from the people I am with.     


Know your limitations, learn to say no, and prioritize:  In this category, it is recommended that the practitioner take a look at his or her work schedule and demands, and consider whether things might be in better balance.  In this age of modern technology, there is always more work to be done than is possible.  With the power of the internet, there is always something we can be doing that is work related regardless of the current situation.  For instance, multi-tasking at home doing work-related activities on the internet while watching television and having dinner with your family. 


Related to knowing your limitations is the ability to “say no” and set appropriate limits.  The positive side of the intensity of graduate training is that one learns how to manage a great number of demands simultaneously and achieve a high level of accomplishment.  However, carrying that level of intensity through to one’s career over the long term can be detrimental relative to burnout.  Mental health practitioners by their very nature are “giving” people.  They may feel guilty about setting limits and having to say “no” especially when you know you have the skill-set to meet the need. Even so, appropriate self-care (and preservation) must take precedence or you will be of no use to anyone (yourself, your family, or your work).    


Change your work patterns. As discussed by Maslach and Goldberg (1998), most burnout prevention strategies focus on the person to the exclusion of the work or work-setting.  It seems to be assumed that work should be stressful and it is up to the individual to figure out how to effectively cope with it.  It is important to look at both person-centered prevention approaches as well as work-focused.  One of the basic recommendations for prevention of burnout is to work less.  This might include working less overall (total number of hours) or changing the pace of the work.  Relative to the latter, some therapists might enjoy a three day weekend and, to achieve this goal, cram all of their work into four 10-12 hour days. This may or may not be a reasonable work pattern over the long term. Changing work patterns also includes achieving a balance between work and “play” as well as pacing work in a more effective manner. 


Don’t go it alone.  Many clinicians are vulnerable to compassion fatigue and burnout secondary to emotional and physical isolation.  This can be addressed in a variety of ways including collegial support and developing a sense of community.  This might be through a peer group, supervision, attending conferences, etc.  It is important to underscore that this should be face-to-face contact and not simply through electronic media. 


Maintain a beginner’s mind.  To maintain one’s interest and quality of life, it is important to cultivate passionate involvement in learning something new.  This might be a hobby, sport, language, a new therapeutic model, etc.  This can help relieve the practitioner of the burden of having to be an expert and gives one the freedom to not know “all the answers.”  No matter how experienced and knowledgeable you are, it is always good to have a teacher of some sort as a way to be nurtured and stay “open” to other ideas. 


Develop a social network.  Similar to not going it alone, it is important to have a social support network outside of one’s professional endeavors.  This involves such things as friends, family, groups, etc.  Whether you are a solo practitioner or employed by an agency, it is important to try and develop a supportive work environment.  In most cases of preventing burnout, the focus is on the individual practitioner “doing something” (person-centered). Developing a supportive work environment involves attempting to change the situation outside of one’s self to make it less stressful and help prevent burnout.  This may take some creative thinking, but options can almost always be developed.  This might include developing a flexible schedule, changing one’s work routine, etc. 


Adopt a long range perspective.  An individual’s work-life balance will change over the course of his or her life.  At any stage of our career and personal lives, transitions will dictate (or should dictate) changing strategies for keeping a healthy balance.  For instance, one may start out specializing in a certain aspect of mental health care and then transition to other areas as interest and situations dictate.  The same is true for personal life transitions such as starting a family, children moving away to college, moving to a different location, etc.  Approaching these transitions with flexibility can help prevent burnout and improve one’s quality of life. 



Table 9. Other Self-care Ideas                  



Self-care might also involve obtaining one’s own psychotherapy when indicated. 


Pay attention to the risk and vulnerability associated with psychotherapy practice.  If you completed the ProQOL, score and analyze the results.  These numbers can help identify areas that may need attention. 


Maintain professional relationships that include opportunities to discuss the nature of your work. 


Seek consultation with peers and experts concerning professional challenges. 


Be aware that the literature has firmly established that all psychotherapists are vulnerable to compassion fatigue, vicarious traumatization, and burnout. 


Pay particular attention to maintaining a balance between work, rest, and play.  Make personal and professional self-care a priority.  Be sure to attend to your physical and spiritual well-being as well as your emotional and psychological health. 


Develop realistic expectations about workload and responsibilities. 


Be aware of the literature related to occupational risks and vulnerabilities for psychotherapists. 


Identify any sources for support for your work and utilize them. 


Take regular vacations and breaks from your work.  These vacations and breaks should be truly high quality and include untethering yourself from electronic attachment to work. 



Beyond Burnout:  Impairment


As reviewed previously, a practitioner may be suffering from compassion fatigue or burnout and not necessarily be impaired. Although, being burned out is one step in a likely progression to actual impairment.  As discussed by Smith and Moss (2009), “One of the primary difficulties in identifying impairment is the lack of consensus regarding its definition” (p. 1).  In the early 1980’s a concept of the impaired professional was developed as “one who is ill, but who is not malicious, dishonest, or ignorant” (as cited in Smith and Moss, 2009, p.2).   This differentiated the impaired professional from one who is unethical or incompetent for other reasons.  Since that time, many definitions of impairment in professionals have been advanced.  Some include the concept of unethical behavior, as well as incompetence, and misconduct.  So far, there is no universally accepted definition but many have been developed.  The American Psychological Association in association with the ACCA and the Association of State and Provincial Psychology Boards (ASPPB) have reviewed many of these.  The theme of most definitions is that it is:


“a condition that compromises the psychologist’s professional functioning to a degree that may harm the client or make services ineffective” 


The definition is consistent with most of the ethical codes of mental health and health providers. It also takes into account that impairment can occur for a variety of reasons ranging from mild symptoms of burnout to the most severe problems (substance abuse, etc.).  Another concept related to impairment crossing over into unethical behavior is:


“…failure to provide services within the professional standards of care due to conduct inconsistent with legal and professional codes or failure to practice within reasonable competency and skill….”


As might be surmised, the line between burnout and impairment is not clear and this is often determined on a case by case basis.  A mental health professional who continues to function while impaired is clearly acting unethically and is at risk for a host of other problems beyond the burnout itself.  Essentially all the ethical codes address impairment in one way or another.  Examples are included in Table 10.



Table 10. Examples Ethics Codes Related to Impairment



American Psychological Association (APA)

2.06: Personal Problems and Conflicts 

(a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.


(b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties. (See also Standard 10.10, Terminating Therapy.)

National Association of Social Workers (NASW)

2.09: Impairment of Colleagues 

(a) Social workers who have direct knowledge of a social work colleague's impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.


(b) Social workers who believe that a social work colleague's impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.


2.10: Incompetence of Colleagues 

(a) Social workers who have direct knowledge of a social work colleague's incompetence should consult with that colleague when feasible and assist the colleague in taking remedial action.


(b) Social workers who believe that a social work colleague is incompetent and has not taken adequate steps to address the incompetence should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

American Counseling Association (ACA): 

C2g. Impairment. 

Counselors are alert to the signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until such time it is determined that they may safely resume their work. Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients. (See A.11.b., F.8.b.)


American Association for Marriage and Family Therapists (AAMFT)

3.3 Marriage and family therapists seek appropriate professional assistance for their personal problems or conflicts that may impair work performance or clinical judgment.


3.15 Marriage and family therapists are in violation of this Code and subject to termination of membership or other appropriate action if they: (a) are convicted of any felony; (b) are convicted of a misdemeanor related to their qualifications or functions; (c) engage in conduct which could lead to conviction of a felony, or a misdemeanor related to their qualifications or functions; (d) are expelled from or disciplined by other professional organizations; (e) have their licenses or certificates suspended or revoked or are otherwise disciplined by regulatory bodies; (f) continue to practice marriage and family therapy while no longer competent to do so because they are impaired by physical or mental causes or the abuse of alcohol or other substances; or (g) fail to cooperate with the Association at any point from the inception of an ethical complaint through the completion of all proceedings regarding that complaint.



The ethical codes indicate that if a clinician is impaired to the point that his or her ability to practice competently is comprised, it is unethical. Even so, there is somewhat of a dilemma.  On the one hand, it is unethical; one the other hand, an impaired practitioner is probably the least likely to do something about it.  This is due to not taking the step of self-analyses and, for those who do, not necessarily taking action to do something about it. Questions posed by Smith and Moss (2009, p. 1) are applicable to all clinicians:


Do you know how to recognize professional impairment in yourself and other?


Do you know what resources are available for addressing impairment among psychologists?


Do you feel comfortable confronting an impaired colleague?


Throughout training, mental health and health professionals are seldom encouraged to express doubts or concerns about themselves, especially in terms of professional behaviors.  Rather, they are encouraged to maintain a visage of confidence, competence and almost invulnerability to stress.  As such, health care providers may tend to either deny the emergence of impairment or rationalize/minimize its significance. The rationalization may be things like, “I have seen others engage in this behavior and nothing bad happened; “the harm done was not intentional”; “there is really little risk of doing harm and of anyone finding out”, etc.  Regardless of the denial and rationalizations, the behavior stemming from impairment is certainly unethical if it crosses the line of impacting professional competence in any way.


Barriers to intervening    


If a practitioner is impaired to the point of being unethical, it is incumbent on him or her to do something about it. However, as we have seen, there are often barriers to the practitioner taking appropriate steps.  In many situations, the first step may be the impairment-related behavior being noticed by a colleague.  If a practitioner is impaired, and this is identified by others, most ethical codes mandate that colleagues intervene in some manner.  However, this may not be that easy and is likely not occurring that often.  Barriers to intervening as reviewed by Smith and Moss (2009) and elsewhere (Intervening with an Impaired Colleague) include such things as a lack of awareness of the hallmarks of impairment if they are subtle, not being comfortable differentiating between distress and unethical impairment, being worried that intervening would result in an adverse outcome for the individual, and being unsure (unaware) of the professional (ethical) responsibility to intervene.


One of the biggest obstacles to intervening is not being sure of exactly what to do.  Vandenbos and Duthie (1986) have outlined a six-step process for confronting and supporting a distressed colleague.  The steps are summarized below and details can be found in the article as well as here. 


1) Evaluate the information


The first step involves collecting and evaluating information related to the colleague's behaviors of concern. It is suggested that one should make a list of concerning and meaningful "behaviors and events". As with most “evidence”, observed occurrences are more persuasive in discussion than second-hand information. In addition, one should obtain more information which might include conversations with other colleagues, or consultation with "experts" in the profession to determine the seriousness of the behavior and the proper course of action.


2) Decide who should confront the individual


This step is designed to ensure the appropriate level of intervention with the impaired colleague. Although those closest to the practitioner may be the most effective, there are situations in which a third party may be more likely to succeed. The person who does the intervention should be equal or greater in power to the impaired practitioner.  This is important in cases of an impaired supervisor, boss, etc. 


3) Prepare before the meeting


Concerned colleagues should organize themselves before approaching the impaired colleague. This is best done by listing issues of greatest concern in concrete and behavioral terms.  One must always pay attention to the social aspects of the intervention, and going from the role of “colleague” to “interventionist”.


4) Consider how to approach the colleague


It is best to keep the discussion strictly to the specifics, especially when first broaching the topic. Describe the evidence and why it is important. Empathy and compassion are essential but must be balanced with clarity and facts.


5) Speak, listen and discuss


Once the case is made, the practitioner should be prepared to listen compassionately and to consider any additional evidence the colleague may present.  Be prepared to admit that a mistake was made, if that is indeed the case.  However, one should always ask for explanations of discrepancies or evasions. Acknowledging the likely discomfort of the colleague will be helpful, as will reminding him or her that you wish to help. Many of the skills of a good therapist will be useful in this phase, but it is important to remember that you are not acting in the role of a therapist.


6) Follow-up


It is suggested that one document the meeting and any agreement reached with the impaired colleague. These notes will provide future reference for contact with the colleague, and in the event that the colleague's behavior deteriorates further, will provide documentation for contact with an ethics board or other authority. One should also be clear about the timing of a scheduled follow-up meeting. That meeting should focus on specifics. It is important that goals and objectives in the plan be discussed directly, and that while remaining empathically flexible, one does not avoid setting limits, if errant behaviors have not been corrected.





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