Monday, 25 January 2016

What I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession

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.

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.

 Elliott, D. M., & Guy, J. D. (1993). Mental health professionals versus non-mental-health professionals: Childhood trauma and adult functioning. Professional Psychology: Research and Practice, 24 (1),  83-90.

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.
SaraKay Smullens, MSW, LCSW, CGP, CFLE, BCD, whose private and pro bono clinical social work practice is in Philadelphia, is a certified group psychotherapist and family life educator. She is a recipient of a Lifetime Achievement Award from the Pennsylvania chapter of NASW, which recognized her longstanding community organization, advocacy, and activism, as well as the codification of patterns of emotional abuse and the development of the model to address it. SaraKay is the best-selling author of Whoever Said Life Is Fair: A Guide to Growing Through Life’s Injustices and Setting YourSelf Free: Breaking the Cycle of Emotional Abuse in Family, Friendships, Work, and Love. SaraKay's professional life continues to be devoted to highlighting destructive societal forces through communication, advocacy, and activism.

This article appeared in the Fall 2012 issue of THE NEW SOCIAL WORKER. Copyright 2012 White Hat Communications. All rights reserved.

Wednesday, 13 January 2016

Real World Clinical Social Work Blog: Twin Traumas

Us and Them

The false dichotomy of us and them.

by Dr. Danna Bodenheimer, LCSW. author of Real World Clinical Social Work: Find Your Voice and Find Your Way

     Following the attacks of September 11, 2001, there was a tremendous amount of literature written about the impact of having a shared trauma in clinical dyads (Coates, Rosenthal, & Schechter, 2003; Pierce, 2006; Tosone, Minami, Bettmann, & Jasperson, 2010). It was an amazing clinical moment, because the shared vulnerability of the therapist and client, alike, was crystal clear. It also became totally acceptable for the therapist to not be more evolved in negotiating trauma than the client. For a moment, we were all admittedly in the confusion, rage, fear, and sadness together.

     What feels so stunning about the passing of that moment is that we, clinically, have lost sight of the very real fact that 9/11 was one of many shared traumas that clinicians and clients co-occupy. It was an acceptable issue, at the time, to discuss, because it was so obvious and so huge and there was no shame in being affected by it.

     I think it is fair to say that we have receded back into the fantastical recesses of believing that our clients are traumatized, while we, their social workers, are not. The power of this false dichotomy pervades our work as we learn about the trauma of our clients, as if we are not talking about ourselves the whole time. Most of the time, our clients have some sort of trauma histories. But the hard truth is that so do we. We, of course, are supposed to be on the side of either not having been traumatized or on the side of having worked through our trauma enough that we are not at risk for feeling triggered or unhinged by our own pasts.

     For starters, let me offer a definition of trauma that will help us all to know what I am talking about. The definition of trauma is clearly debatable and complex. To combat that, I am going to use the Webster’s definition of it, to simplify that part of the discussion. The dictionary defines trauma:

1.       an injury (as a wound) to living tissue caused by an extrinsic agent

2.       a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury

3.       an emotional upset

     The broadness of the definition of trauma is useful here, because I am trying to acknowledge the far-reaching impact of trauma. To add to the definition, I will say (in my own words) that trauma usually includes an attack on an attachment, a feeling of being out of control, and a loss of internal and external sites for safety.

     We don’t know how many people are traumatized. It would be impossible to calculate, not only because of underreporting, but because we don’t all fully agree on the definition of it. We do know (at the least) that 1 in 4 college women report having been sexually assaulted in their lifetimes. That number has remained constant since the 1980s. And that is just sexual assault. Given that statistic alone, it makes sense to finally acknowledge that clinicians are often trauma survivors, and we bring this to our treatment.

     I write this as a trauma survivor, myself. In a way, I feel inhibited saying that and at the same time, of course, there really shouldn’t be any surprise there. There are many of us who are trauma survivors, and oftentimes the only thing that separates one trauma survivor from another is the willingness to identify as such.

     Okay, so what about all of this? What does it mean if we ourselves are traumatized? Can we still be good at our jobs? How evolved beyond our trauma do we have to be?

     I operate with these questions in mind all the time. I think about them as a professor, a therapist, and a supervisor. I know my students, when I am teaching about trauma, are trying to learn more about their clients, but are also listening for information to better understand themselves. I see them taking dutiful notes, while I see them internalizing the information to deepen their own understandings of themselves. I know they are hiding this, and I also want them to really know that it is okay.

     I want you all to know that it is okay that you have been traumatized. I want you to know that it is okay that sometimes you feel really triggered and scared and ashamed. I know that you wonder if you can be good at this work when you have been through your own histories, and I know that this question is terrifying.

     It is amazing, because in the field of substance abuse, there is shame when the clinician has not been through some sort of addiction and come out the other side. Clinicians who are not sober often wonder if they can really help their addicted clients. Why is the opposite true for trauma? Why are we often made to feel that if have been traumatized, we can’t help people because we are too messed up? Perhaps the answer has something to do with gender, but I don’t think it is that simple. And I am not exactly sure that the answer matters. What does matter is that the shame transforms into something else, something powerful.

     This is what I have come to believe: I am not sure that we can do this work well unless we have gone through some sort of a trauma.

     There is something quite magical and painful about the traumatized mind.

     The traumatized mind is one that is highly sensitive, attuned, and capable of understanding nuance and complexity. It is sensitive because traumatized folks typically had to study their abusers to try and survive their trauma. This study of psychology was initiated by something horrible, but it was initiated early and has left many of us as experts in our field. It is attuned because those who have been traumatized have typically learned how to really tune into the needs of others in order to keep themselves safe. This is a complex phenomenon and typically the byproduct of two things. First, for many who have been traumatized, the pain of being in one’s own mind can be unbearable, and we have vacated our own mind to be in the mind of another for relief. Second, because we know the pain of trauma so well, we can carefully pick up on it in others. Some say that those who have survived trauma have antennae. I think this is true. Trauma survivors are capable of understanding complexity and nuance, because many of us know our abusers and simultaneously love and hate them. We know that many emotions can be held at one time, because we have done it ourselves. Ambiguity is something we are well versed in.

There is a sense, oftentimes, that we should be solutions oriented, identify goals, and arrive at clear destinations in treatment. For example, if a woman is being physically attacked by her husband, she should leave. But the statistics state that it takes about 7-8 times to finally leave a truly abusive relationship. The parts of ourselves that won’t acknowledge the complexity of trauma can become easily frustrated by the 5th time. The parts of ourselves that do acknowledge the complexity of trauma can dig deep within to know the depth of self doubt that comes with trauma and abuse and can find more empathy for the struggling client.

     I don’t suggest that we should be activated by PTSD symptoms in order to practice effectively. Our trauma is something that we need to have worked on and made some meaning of. However, the truth about trauma work is that it is alinear and often laboriously sluggish. We don’t need to be at the other end of our work to help a client out. There is no other end, really. Instead, I am arguing that there is a clinical space between being totally healed (a myth) and totally activated (a danger zone) from which our best work can occur.

     Yesterday, I had a supervisee describing a case that had powerful overlapping qualities with my own story. I felt myself moving between a million different places internally. The first was the wish to run. The second was the wish for simple answers and demands (tell her to get out!). The third was a pathologization of the client. The fourth was physical disgust. The fifth was doubt about the client’s actual story, and the sixth was some dissociation about what I was having for dinner. The last was the ability to finally sit still and hear the story unfold. These are crazy places to go. But the truth is that these are the places that the client is moving between, as well - the doubt, the oversimplification, the self blame. If I were not able to visit these places myself, I could never properly understand the perimeter of the clients’ walk around the crevices of their own mind.

     My own therapy and clinical work has offered me the space to finally sit still. It has also offered me the possibility of observing all of these internal states and to survive them intact and not overly stimulated. Do I wish that I went to all of these places? Of course not. It is crazy making. But could I really offer the possibility of my client ever being able to observe their own self states and find an internal safe haven without my own stuff? I doubt it. Somehow I just doubt it.

     9/11 was a long time ago, but our world is not less traumatized and neither are our individual psyches. If anything, things feel harder and more painful now than they did then. I think that true clinical social work calls for the honoring of that truth. I also think that it calls for the refusal to separate ourselves from our clients in some deceptively binaried way that denies the complexity of our internal worlds. It is precisely this complexity, our ability to know darkness and light, which truly helps us to read the whole truth of our clients’ suffering. 


Coates, S. (Ed), Rosenthal, J. (Ed), & Schechter, D. (Ed). (2003). September 11: Trauma and human bonds. The Analytic Press/Taylor & Francis Group, New York, NY. 

Pierce, M. (2006). Intergenerational transmission of trauma: What we have learned from our work with mother and infants affected by the trauma of 9/11. The International Journal of Psychoanalysis, 87(2), 555-557.

Tosone, C., Minami, T, Bettmann, J.; Jasperson, R. (2010). New York City social workers after 9/11: Their attachment, resiliency, and compassion fatigue. International Journal of Emergency Mental Health, 12 (2), 103-116.

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way.