What
I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession
by SaraKay Smullens, MSW, LCSW,
CGP, CFLE, BCD
(Editor's Note:
This article won the 2013 NASW Media Award for best magazine article. SaraKay
Smullens' book, Burnout and Self-Care in Social Work, which grew out of this
article, is now available, as of July 2015. The book's foreword is by Linda May
Grobman, publisher/editor of The New Social Worker. Read an interview with
SaraKay.)
The
training to become a social worker is arduous, demanding, and complex. My
concentration was clinical social work, which during my graduate education was
known as casework. I well remember
studying my basic curriculum; taking more electives than were required;
receiving excellent supervision of my clinical work with individuals, couples,
families, and groups; and before it was required, taking many continuing
education classes.
Suffice
it to say, I learned a great deal—but what it seemed that no one shared with me
during these years, or seemed to discuss among themselves as either teachers or
therapists, was the sheer exhaustion experienced in clinical work as we do our
very best to meet the needs of others day after day, year after year. When one
of my deeply trusted supervisors died, and I met his wife for the first time,
she told me that sometimes he would return home too exhausted to even speak,
and that a frequent statement she heard from a man who obviously treasured his
clinical work, teaching, and writing was: “They feel better, but I surely do
not.” How well I understood this feeling, I thought. How well so many in our
field must understand this feeling. And yet many of us lack the attendant
knowledge that can assess and direct this feeling, which is called “burnout” in
the literature—or knowledge of the necessary practices to heal and soothe
ourselves, which are collectively known as “self-care.” What I have learned
over the years is the necessity of addressing this complicated exhaustion
before the feeling of depletion leads to dysfunction and beyond. With this in
mind, I share the precise information that I wish I had known about “burnout”
and “self care” in the early years of my work, with references for your further
study.
The Problem of
Burnout
“Burnout”
as a term was first applied by Freudenberger (1975) to describe what happens
when a practitioner becomes increasingly “inoperative.” According to
Freudenberger, this progressive state of inoperability can take many different
forms, from simple rigidity, in which “the person becomes ‘closed’ to any
input,” to an increased resignation, irritability, and quickness to anger. As
burnout worsens, however, its effects turn more serious. An individual may
become paranoid or self-medicate with legal or illegal substances. Eventually,
a social worker afflicted with burnout may leave a promising career that he or
she has worked very hard to attain or be removed from a position by a forced
resignation or firing.
In
the intervening 37 years, burnout has been the focus of several studies, each
of which has affirmed the phenomenon (van der Vennet, 2002). We may
instinctively realize that therapeutic work is “grueling and demanding” with
“moderate depression, mild anxiety, emotional exhaustion, and disrupted
relationships” as some of its frequent, yet common, effects (Norcross, 2000).
We may even have gotten used to some of the factors promoting burnout such as
“inadequate supervision and mentorship, glamorized expectations...and acute
performance anxiety” (Skovholt, Grier, & Hanson, 2001). Yet, as social
workers, we may still not pay full attention to the reality of burnout until
suddenly everything seems overwhelming. At such times, we may lack the
knowledge of what is transpiring or the critical faculties to assess our
experience objectively that would enable us to take proper measures to restore
balance to our lives.
To
explore and understand the phenomenon of burnout before it is too late,
researchers have found it useful to introduce several components of the term or
attendant syndromes, specifically compassion fatigue, vicarious trauma, and
secondary traumatic stress. Although there is a great deal of overlap among
these terms, each of them poses a particular risk and originates from a
different place in the practitioner’s experience or psychology.
Compassion
Fatigue
Compassion
fatigue is perhaps the most general term of the three and describes “the
overall experience of emotional and physical fatigue that social service
professionals experience due to chronic use of empathy when treating patients
who are suffering in some way” (Newell & MacNeil, 2010). There is evidence
that compassion fatigue increases when a social worker sees that a client is
not “getting better” (Corcoran, 1987). Yet, a large part of compassion fatigue
is built directly into the fabric of the kind of work we do. Although we may
strive for a relationship with our clients that is collaborative, our goal is
not a relationship that is reciprocal. In many important ways, reciprocity is
unethical, even illegal. Although recognizing this fact can lead to an
important setting of boundaries, including financial boundaries (charging
clients, collecting co-pays), or deciding how missed appointments are handled,
compassion fatigue may reflect a deeper “inability to say no,” one of the
hazards that “can exacerbate the difficult nature of the work” (Skovholt,
Grier, & Hanson, 2001).
In
our work, although we are surrounded by people all day long, there is not a
balanced give and take. Concentration is on clients, not ourselves. In the
truest sense, we are alone—we are the givers, and our fulfillment comes from
seeing the growth, hope, and new direction in those with whom we are privileged
to work. The fulfillment of our professional commitment demands that we ever do
our best and give as much as possible in the ethical ways that are the
underpinnings of the social work profession. With this awareness, common sense
predicts that burnout is a potential threat waiting for us in the wings.
However, as we all know, common sense and clear thinking can be eroded when our
own unfinished emotional business propels us. Although there are many
therapists who describe fulfilling childhoods that are secure and stable,
research indicates that the majority who come into our field have known profound
pain and loss during their formative years (Elliott & Guy, 1993). Most have
experienced one or a combination of five patterns of emotional abuse, which has
led to the relentless need to give to others what we wish we had received,
coupled by an inability to care for oneself and set limits in order to
counteract exhaustion (Smullens, 2010). Social workers, therefore, are
especially prone to compassion fatigue, not only because of the nature of our
work, but often because our own natures have inspired us to enter this precise
field.
Vicarious
Trauma and Secondary Traumatic Stress
Vicarious
trauma (also known by the closely related term “secondary traumatic stress”)
results from a social worker’s direct exposure to victims of trauma. Unlike
compassion fatigue, vicarious trauma may have a more immediate onset (Newell
& MacNeil, 2010), as such exposure triggers the immediate re-experiencing
of painful occasions from the practitioner’s personal history. As mentioned
above, social workers are far more likely to have painful personal histories
than those working in other professions or vocations. Elliott & Guy (1993)
found, for example, that women working in the mental health professions were
more frequently traumatized as children by physical abuse, alcoholism, emotional
and sexual abuse, and familial conflict than were women working in other
fields. Additionally, women therapists appear to come from more chaotic
families of origin, with significantly lesser experiences of familial cohesion,
moral emphasis, and achievement orientation.
Although
I have separated vicarious trauma from compassion fatigue for ease of
categorization, it is quite likely that they influence each other—that is,
vicarious trauma provokes and promotes compassion fatigue, while the origins of
compassion fatigue—an inability to establish proper boundaries—can be found in
the social worker’s trauma history. Unfinished emotional business can involve
all aspects of our personal and professional lives. Do we have issues with
members of our family of origin that are unresolved and drain present
relationships, keeping us from seeing clearly? Do we long to do the impossible
for a deceased or suffering parent? Do we long to establish closeness with a
family member who has continuously made it clear that this is not a mutual
desire? Are there present issues regarding a partner, or sexual preference? Are
we struggling to find the intimacy we crave, yet still eludes us? The list, in
myriad forms, can go on and on. It is essential to remember that when our clients
bring these very same issues to us that we have not faced, burnout and the
depression that accompanies it can and will set in, leading to emotional
exhaustion, depersonalization, and a decreased sense of personal
accomplishments.
Through
the agencies of compassion fatigue and vicarious trauma, burnout systematically
decreases our ability to relate to our clients, which strikes at the heart of
our self-identification as a healer or positive force in society. This in turn
results in increased disaffection for our work, disconnection, and isolation.
This isolation may in fact already be present; Koeske and Koeske (1989) found
that in addition to demanding workloads, one of the causes for burnout was low
social support, particularly low co-worker support.
Fortunately,
as Poulin & Walter (1993) noted in their one-year study of nearly a
thousand social workers, just as burnout is associated with personal and
professional factors, adjustment to those factors prevents future or further
burnout from occurring. Further, it can reverse burnout that has occurred. In
other words, there is a cure for burnout—not a permanent cure, or a cure-all,
but a process that can be engaged to restore balance in our personal and
professional lives. That cure is self-care.
Self-Care as the
Antidote to Burnout
Lately,
there has been increased attention on the concept of self-care—the balancing
activities in which social workers can engage to preserve personal longevity
and happiness, their relationships, and their careers. These activities of
self-care span a wide range and can include: receiving support from mentors or
a peer group, the importance of relaxation (including vacations), personal
endeavors that are non-professional activities, and the need to balance
wellness with one’s professional life.
By
engaging in self-care, we can assert our right to be well and reintroduce our
own needs into the equation. Hearing this call may be a difficult first step,
as social workers might feel guilt about needing to take care of ourselves—especially
since, as was pointed out previously, mental health workers are more likely to
“come from chaotic families of origin” where they adopted co-dependent/parenting
roles.
In
a study comparing psychotherapists and physicists, psychotherapists were significantly
more likely to perceive themselves as assuming a care-taking role than were
physicists (Fussell & Bonney, 1990). The same study showed that
psychotherapists also experienced significantly more parent-child role
inversion (parentification) than did the physicists. This does not mean that
the caregiver choice of career is a negative thing; it can be a healthy and
healing choice, once we recognize the need to engage in self-care. When we do
embrace self-care, we find many different strategies at our disposal that span
the entire gamut of human experience. There are self-care solutions in the
emotional, physical, social, intellectual, sexual, and spiritual dimensions of
life that underscore our humanity.
There
have been several attempts to categorize self-care strategies, notably: Mahoney
(1997) and Norcross (2000). Norcross outlines 10 self-care strategies,
including seemingly obvious—yet incredibly valuable—pieces of advice, such as
recognizing the hazards of psychological practice and beginning with self-awareness
and self-liberation. Three of Norcross’s strategies are of special note, and I
will now discuss these in greater detail.
1.
Employ stimulus control and counterconditioning when possible.
This
strategy is actually two common sense, personal organization strategies in one,
which I refer to as “necessary selective gifts to oneself” in a setting where
you will spend more daytime hours than you spend at home. The first, “creating
a professional greenhouse at work” (Skovholt, Grier, & Hanson, 2001),
involves decisions such as the resolve to eat lunch at one’s desk as little as
possible, the importance of social exchange as well as a comfortable chair,
providing calming music as background for writing and thinking, and taking
plants to your office. (A personal aside about plants: I well know that
forgetting to water them is a sure wake-up call that you are not giving
yourself what you need.)
The
second part of this strategy is the “counterconditioning” that physical
activities, healing modalities, and the diversion of reading and films, to cite
some examples, can provide. Is there a gym you can visit first thing in the
morning or after hours? Would it center you to visit a place for worship during
your lunch break or on your way home? Would you like to hear a book-on-tape at
certain hours? In one study of self-care strategies, Mahoney (1997) reported
pleasure reading, physical exercise, hobbies/artistic pursuits, and
recreational vacations as the most commonly reported self-care activities,
followed by practicing meditation and prayer, doing volunteer work, and keeping
a personal diary.
2.
Seek personal therapy.
Nearly
90% of mental health workers seek personal therapy before, during, and after
their professional training (Mahoney, 1997). In addition, more than 90% of
those who do seek personal therapy derive satisfaction and growth from their
experiences therein, creating more fulfilling lives (Norcross, 2000). Toward
this end, when we need consultation, we must seek it; and if such consultation
directs us to deeper psychological work, we must not deny this necessity
3.
Diversify, diversify, diversify.
Whereas
clinical responsibilities can totally deplete us, we can also use our hard won
skills in various ways that replenish us. Many find balance, camaraderie, and
stimulation through ongoing discussion groups with colleagues. Others find it
by shifting client focus. For instance, those of us concentrating primarily in
group therapy can also turn to individual, conjoint, and family therapy for a
small part of our practice. I have found it invigorating to combine marital
work and group therapy in an unusual way. For marital clients with complex
problems, I place the couple in separate groups, trying to find one in each
group who will remind each of his or her partner.
Another
important sustaining resource is to use hard won skills in areas other than
clinical practice. A few years ago, for example, I became a clinical consultant
to a local Philadelphia theater company, meeting with directors and cast members
to discuss the lives of actual clients (disguising all recognizable aspects of
lives, of course) that parallel lives and events in the plays. My most
memorable experience was consulting work done on the very controversial play
Blackbird, by David Harrower. Blackbird is a play about sexual abuse, as well
as the pain and loneliness that can lead to this horrific act. One of the most
poignant moments in my professional life occurred during a TalkBack for this
play, when an audience member confided that she had been abused, and her
assailant had never owned this abuse or apologized. But she explained that
events in this play felt as if an apology had been made to her, and would help
her to heal.
My
life and work have taught me that the strongest lesson in avoiding burnout
through self-care is to accept that we are human, and in that we are each
limited and—yes—flawed. Despite best intentions and very hard work, we will
each experience failure, and our losses and the losses of those dear to us will
bring the most unbearable pain imaginable.
Yet,
with all of the pain and loss of life, we can, if we will it, grow and learn
and move forward in our life journey. If we hold on to this, we can understand
how important self-care is. It will give us the strength to claim the joys of
living and endure what we must. And it will help us to assure that our clients
are able, whenever possible, to do the same.
References
Corcoran,
K. J. (1987). The association of burnout and social work practitioners’
impressions of their clients. Journal of Social Service Research, 10 (1),
57-66.
Freudenberger,
H. J. (1975). The staff burn-out syndrome in alternative institutions.
Psychotherapy: Theory, Research and Practice, 12 (1), 73-82.
Fussell,
F. W., & Bonney, W. C. (1990). A comparative study of childhood experiences
of psychotherapists and physicists: Implications for clinical practice.
Psychotherapy, 27 (4), 505-512.
Koeske,
G. F., & Koeske, R. D. (1989). Workload and burnout: Can social support and
perceived accomplishment help? Social Work, 34 (3), 243-248.
Mahoney,
M. J. (1997). Psychotherapists’ personal problems and self-care patterns.
Professional Psychology: Research and Practice, 28 (1), 14-16.
Newell,
J. M., & MacNeil, G. (2010). Professional burnout, secondary traumatic
stress, and compassion fatigue: A review of theoretical terms, risk factors,
and preventive methods for clinicians. Best Practices in Mental Health: An
International Journal, 6 (2), 57-68.
Norcross,
J. C. (2000). Psychotherapist self-care: Practitioner-tested, research-informed
strategies. Professional Psychology: Research and Practice, 31 (6), 710-713.
Poulin, J. & Walter, C. (1993). Social worker burnout: A longitudinal study. Social Work Research & Abstracts, 29 (4), 5-11.
Skovholt,
T. M., Grier, T. L., & Hanson, M. R. (2001). Career counseling for
longevity: Self-care and burnout prevention strategies for counselor
resilience. Journal of Career Development, 27 (3), 167-176.
Smullens,
S. (2010). The codification and treatment of emotional abuse in structured
group therapy. International Journal of Group Psychotherapy 60 (1), 111-130.
van
der Vennet, R. (2002). A study of mental health workers in an art therapy group
to reduce secondary trauma and burnout. Dissertation Abstracts International,
63 (9-B), 4389. (UMI No. 3065615).
Additional
Reading
Smullens,
S. (2012, Summer). Self-care and avoiding burnout. NASW Private Practice
Section Connection, Summer 2012.
http://www.sarakaysmullens.com/media/2012PrivatePracticeNL-NASW.pdf.
This article appeared in the Fall 2012 issue of THE NEW SOCIAL WORKER. Copyright 2012 White Hat Communications. All rights reserved.
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