Therapists often encounter experiences in therapy that elicit emotionality, this could be in the form of self-of-the-therapist issues, compassion fatigue, or professional burnout. Whereas approaches to supervision for self-of-the-therapist issues recognize the need for accessing the supervisee’s emotionality, approaches have not focused on how the clinical and professional system could also be part of the cycle. We propose an adapted emotionally focused supervision approach that employs steps one through six of the EFT model. To display how this approach would work, we provide the example of work with longer-term clients. Working with longer-term clients can be a challenge for many therapists, and both the professional and client system come with factors increasing emotional risk to the therapist. Engaging the therapist’s emotionality through supervision has the potential to improve therapeutic outcomes, as well as reduce loss of good therapists in the field to professional burnout.
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Imagine one of the following situations. You arrive at your agency one morning with a new client scheduled to see you, one that been seen at the agency off and on for the past couple of years and is now scheduled with you. Or, perhaps you are having your first session with a new client at your private practice when you find out the client has been in treatment for 2 years and expects to see you continuously, and indefinitely. Or maybe, you are on your 43rd session with one of your clients, reflecting on the case and its progress. What are your thoughts, feelings, or reactions? Were they positive or negative? Was your first feeling dread or excitement? Did you feel hope or worry? Did you first think about the client’s potential background or history or your past experiences with long-term clients? If your first reaction was fatigue or apprehension, you are not abnormal, and in fact may be reacting normally given your experiences within different systems. Within the field, within an agency, or even within a therapy room, different experiences or messages are likely present that can deeply impact a therapist’s emotional reaction to any client or any presenting problem.
These reactions that a therapist may experience with cases could be a variety of things, it could be a result of self-of-the-therapist issues (Lum 2002; Timm and Blow 1999), compassion fatigue, professional burnout (Newell and MacNeil 2010), or some combination of the above. For therapists experiencing any of these reactions, seeking supervision to manage them is advised. Presently, most of the approaches to supervision for managing these normal responses have primarily been individually focused or lacking a direct focus on the emotional process. For example, where supervision to process self-of-the-therapist issues recognizes the supervisee’s family system influences, and directly accesses emotion (Timm and Blow 1999; Wetchler 1999), it doesn’t move beyond those pieces to simultaneously address how the clinical system the therapist presently is in is contributing to the experience. On the other hand, where compassion fatigue and professional burnout acknowledge systemic influences on the therapist’s emotional experience, supervision in these approaches generally advises self-care first, and does not directly address emotionality in the context of the clinical system (Figley 2002b).
We believe that emotional reactions to clients can happen with a variety of different clients, situations, or presenting problems, and can be the result of multiple systemic influences. Such emotions should warrant processing in supervision prior to it becoming problematic in the therapist-client relationship (Watson 1993). In order to address the emotional impact from multiple systems on mental health professionals, we will present in this paper an approach to supervision adapted from Emotionally-Focused Therapy (EFT; Greenberg and Johnson 1988). In order to provide a depiction of how multiple systems within the field can affect the emotional experience of a therapist, we will focus on experiences of compassion fatigue and professional burnout that can arise when working with long-term clients. As supervisors, we experienced this type of treatment bringing up emotional reactions with multiple supervisees. We will first present factors that could influence a therapist and affect their emotional experience, and then depict how to apply our adapted supervision approach within this context.
Emotional Risk for Mental Health Professionals
A career as a mental health professional can be an incredibly rewarding experience, but also comes with the potential for a variety of issues, including self-of-the-therapist issues (Timm and Blow 1999), compassion fatigue, secondary trauma, vicarious trauma, and professional burnout (Newell and MacNeil 2010), of which can arise when working with a long-term client. Each of these potential issues has its own signs and symptoms, requires different attention to be managed or prevented, and likely derives from a different systemic influence. We define these differing experiences here.
Self-of-the-therapist issues are reactions that therapists have to their clients that are related to family of origin experiences (McGoldrick 1982), similar to what might be called countertransference (Scharff 1992). Therapists may face times when their client’s presenting problem includes elements that remind therapists of their own experiences in childhood (Timm and Blow 1999). Therapists’ own family system experiences can trigger this, and all therapists will experience this to some extent at some point in their clinical work. Facing a reminder of these lived experiences, a therapist may feel a block in session, avoid intensity in session, side with one family over another, be pulled into the family system (Timm and Blow 1999), or skew client information (Lum 2002). Therapists’ should have an awareness of how their own issues can come up in treatment. This awareness is crucial to maintaining an ethical practice and avoiding inadvertent consequences, including ineffective interventions, in treatment (Timm and Blow 1999). The longer a therapist is working with a client, and the more the therapist is exposed to the client’s story, arguably the more opportunities there are to have a countertransference reaction. Long-term clients may elicit this from therapists for that reason, or because of their presenting problem, which is likely to be related to trauma. Self-of-the-therapist issues do not always negatively affect treatment, sometimes they can present as a strength wherein the therapist can understand the clients’ experiences better and identify pertinent interventions (Timm and Blow 1999). The therapist’s emotional reaction to a case can be a cue that self-of-the-therapist issues are at work.
Professional burnout is a multidimensional construct that includes “three key dimensions …overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment” (Maslach et al. 2001, p. 399). Professional burnout can originate with individual, organization, or client factors (Newell and MacNeil 2010). Secondary traumatic stress and vicarious trauma (Lerias and Byrne 2003) are most common for those professionals who work regularly with clients who have experienced trauma. Vicarious trauma is a more mild form of stress, where the outcome is more cognitively related, and primarily involves a change in thoughts surrounding the perception of trust, safety, and control (Newell and MacNeil 2010; McCann and Pearlman 1990). Secondary traumatic stress (STS), on the other hand, is not limited to cognitive changes, but also includes behavioral symptoms, similar to that of a posttraumatic stress disorder (PTSD) (Figley 2002a). STS can include reoccurring recollections of the event, dreams about the event, feelings that one is experiencing the traumatic event, and efforts to avoid potential triggers for recollections of the trauma. STS accompanies the feeling of psychological distress similar to that which accompanies direct experience of trauma (Figley 2002a).
In some ways, compassion fatigue is synonymous with vicarious traumatization and secondary traumatic stress (Figley 2002a, b; Bride et al. 2007). Assessment measures for compassion fatigue also include job burnout as part of its operationalization (Adams et al. 2006). Compassion fatigue has become an overarching term to describe and account for each of these experiences, and has been used as a term to comprehensively account for the risks clinicians face when working with clients who have been traumatized (Bride et al. 2007), which is likely for clients needing long-term treatment. Compassion fatigue, however, develops over a longer course of time as stress accumulates, as compared to vicarious trauma and secondary traumatic stress where the onset may be more acute (Newell and MacNeil 2010). Thus, the longer a therapist is working with one particular client, the more vulnerable he or she becomes to experiencing compassion fatigue. It is through a therapist’s channeling of empathy, concern with the client’s needs, empathic response, along with regular exposure to the stories of clients’ suffering which can lead to a sort of residue of emotional energy that causes stress to the clinician (Figley 2002b). Multiple systems contribute to the risk of professional burnout or compassion fatigue in long-term therapeutic work. The professional system and the employment system have unique messages and challenges that can increase the likelihood for professional burnout with long-term clients, whereas the unique experiences and needs of the client system in long-term treatment can lend to compassion fatigue.
Systemic Influences on Reactions to Long-Term Therapy
Exposure to the Benefits of Brief Therapy
Experiences therapists have within the field can influence their reactions to clients. In the field of Marriage and Family Therapy (MFT), one of our core approaches to treatment is a brief therapy approach. Brief therapy has manifested with the growing popularity of solution-focused and behavior-oriented treatment modalities (de Shazer 1988; de Shazer et al. 1986; Gingerich and Eisengart 2000). Brief therapy is generally defined as 6 sessions, but lasts anywhere from one session to 12 sessions in practice (Gingerich and Eisengart 2000). In an examination of therapists around the country, around 41.8 % of cases were reported as lasting 10 or fewer sessions, with the average number of sessions for couple’s therapy being 11.5 sessions, family therapy being 9 sessions, and individual therapy 13 sessions (Doherty and Simmons 1996). There are many benefits of short-term therapy, including ease of systematic testing and validation through research and attractiveness to insurers and government funders (DeLeon et al. 1991; Gingerich and Eisengart 2000). Having knowledge of the many benefits of short-term treatment, both from research and insurers in the field, could then potentially affect a therapist’s work with long-term clients creating tension and confusion over long-term therapy’s place. It can happen where clinicians working with clients who require longer-term care begin to judge their capability as a professional. This is especially if their training does not balance a presentation of the benefits of brief therapy with the research that it may not be an effective approach for a subset of clients (Leichsenring and Rabung 2011). Around 50 % of clients see a significant improvement after only 8 sessions, and 76 % see improvement by 26 sessions (Howard et al. 1986). Clients with what is described as complex mental disorders, meaning a client diagnosed with a personality disorder, with multiple mental disorders, or with a chronic mental disorder, experience significantly better outcomes from longer-term psychotherapy, meaning “at least a year or 50 sessions”, as compared to shorter-term treatment (Leichsenring and Rabung 2011, p. 15). These clients may not follow the typical pattern that other clients do, and may challenge the therapist in that way.
AAMFT Ethical Code
Another factor that could make the therapist experience stress and burnout over long-term treatment could be in reflection of the field’s code of ethics. The AAMFT Code of Ethics has a clear stance that treatment should not foster dependency; AAMFT ethical code 1.9 refers to the benefit of treatment for the client, and states “Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship” (American Association for Marriage and Family Therapy 2015). It is incredibly important that professionals are supporting the autonomy of the client, and they do not take advantage of the client’s trust, using it for their own benefit. It would certainly be unethical for a therapist to encourage a client to continue with treatment primarily because of the financial gains to be had for keeping the client on the therapist’s caseload. Clinicians are taught not to foster dependency from the beginning of their training. This code is important for an ethical approach to treatment, something that should be an ongoing consideration for clinicians. However, as therapists reflect on this code, they could begin to feel guilty for allowing treatment to continue with long-term clients. Therapists could begin feeling conflicted about whether treatment should continue, and worry that they are violating an ethical code by continuing treatment.
Nature of the Client’s Presenting Problem
The nature of the types of cases that therapists work with, especially if they are working regularly with long-term clients, can also affect their emotional reaction. Compassion fatigue is a risk, especially to those treatment providers that work with traumatized clients (Adams et al. 2006; Figley 2002b; Newell and MacNeil 2010), as are self-of-the-therapist issues if the therapist has experienced trauma. Although not all long-term clients may present for treatment to focus on an experience of trauma, many will. Those clients identified as benefiting from long-term treatment (Leichsenring and Rabung 2011), those with chronic mental disorders, personality disorders (Yen et al. 2002; Zanarini et al. 1998), or multiple mental disorders (Galatzer-Levy et al. 2013; O’Donnell et al. 2004), are associated with having experienced trauma. In fact, having experienced trauma and developing posttraumatic stress disorder (PTSD) itself is related to having multiple (i.e., comorbid) mental disorders (Galatzer-Levy et al. 2013). Regardless of whether the long-term client has experienced trauma or not, the type of clinical work, and emotional resources required by the therapist working with long-term clients are similar and include many of the same risks as those required for working with traumatized clients.
Similar to work with trauma victims, clinicians also have to use their empathic ability, concern, and response for the long-term client. The exposure to the client being ongoing with, perhaps, a perceived lack of improvement can challenge therapists’ sense of achievement (Figley 2002b), can create a sense of helplessness (Figley 2002b; Pearlman and Saakvitne 1995), can stir a feeling of grief, or can provoke feelings of fear (Pearlman and Saakvitne 1995). Many therapists identify themselves as a helper to others, working with a long-term client could cause a therapist to feel like they are failing at their duty (Pearlman and Saakvitne 1995). Clients’ experiences or responses to treatment may be contrary to therapists’ previous experiences, expectations, or central beliefs about the world and thus may challenge therapists’ core beliefs and cause distress (Figley 2002b). Engaging empathic response over a prolonged period, and for a client who has had difficult life experiences, can be taxing. Repeatedly engaging feelings of hurt, fear, sorrow, or any other emotion the client may be experiencing alone may exhaust therapists (Figley 2002b). With multiple risk factors being present, the need for therapists who work with this population to consider how to prevent compassion fatigue, and to consider what role it could play in their ongoing work, is crucial.
Managing Emotional Risk with Long-Term Clients
Therapists have an ethical responsibility to manage any emotional risk they experience, especially related to compassion fatigue and burnout (for AAMFT ethical codes see Negash and Sahin 2011). We first want to echo the community of scholars focused on this research area who have identified the importance of supervision for managing this distress (e.g., Lakey and Cohen 2000; Pearlman and Saakvitne 1995; Ray and Miller 1994). The importance of a safe supervision environment for such work to be effective should be at the forefront of any adapted supervision approach (Emerson 1996). In addition to supervision, there are several approaches to managing emotional fatigue, and resources potentially available in one’s professional setting (Pearlman and Saakvitne 1995). The use of a preventative team is one way of achieving this. Preventative teams adapt the treatment team approach to therapy by encouraging regular communication between team members while continually validating the experiences of the client and assessing the needs of the clinician (Munroe et al. 1995). We believe it is of the utmost importance for therapists to responsibly deal with a very normal experience that they will have, and therefore, to manage self-of-the-therapist issues, compassion fatigue, or professional burnout we suggest therapists seek supervision.
There is a high risk for professional competence and integrity to be compromised if any issues are not attended to. Inability to manage compassion fatigue leads to detrimental results for clients and for therapists’ effectiveness as providers (Gelso et al. 2002). Or, could lead the therapist to engage in inappropriate behaviors or ethical violations if they don’t manage self-of-the-therapist issues, this could include inappropriate dual relationships (Timm and Blow 1999). Both therapists and their supervisors identify greater positive client outcomes when therapists are perceived to maintain good anxiety management and conceptualizing skills (Gelso et al. 2002), Furthermore, therapists note better client outcomes when they perceived themselves to have better self-integration (Gelso et al. 2002). The paradox with this is that if the therapist has compassion fatigue or burnout because the client is a long-term client, that stress negatively affects the client and stunts outcomes, which can lead to treatment taking even longer. When a therapist is colder, more detached, less engaged, less responsive or even more silent, however, the alliance with a long-term client may be in jeopardy and could influence the outcomes of treatment (Hersoug et al. 2009).
The notion of managing therapist issues including self-of-the-therapist issues and compassion fatigue are not new; there is even an entire book dedicated to the treatment of compassion fatigue (Figley 2002a). The suggestion of self-care and a good work-life balance, however, has been the obligatory response to managing the therapist’s emotional exhaustion (Figley 2002a, b; Lum 2002; Negash and Sahin 2011; Newell and MacNeil 2010; Pearlman and Saakvitne 1995; Stamm 1999). The implication is that taking better care of one’s self can lead to better capacity to be empathetic in sessions. Activities the therapist could engage in for self-care include journaling (Becvar 2003), yoga (Valenta and Marotta 2005), meditation or other breathing exercises (Becvar 2003; Figley 2002a), and engaging social support (Figley 2002b). Little has been suggested for managing compassion fatigue beyond the notion of self-care, and even less has been deliberated in regards to the effectiveness of current self-care implementations, particularly within the field of marriage and family therapy. As Rosenberg and Pace (2006) suggest, the systemic nature of our field and the preferred treatment of families rather than individuals may result in elevated experiences of stress. Research has also demonstrated that male therapists, compared to female therapists, are more likely to experience a particular type of burnout, or indicator of compassion fatigue, depersonalization—an emotional disconnect or lack of care for their client’s outcomes (Maslach and Jackson 1981; Rosenberg and Pace 2006). The few other suggestions of what a therapist can do to combat this stress includes psychoeducation (Figley 2002b), behavioral approaches including desensitization methods and exposure therapy (Figley 2002b), cognitively-focused approaches (Pearlman and Saakvitne 1995), and practicing disengagement from the client between sessions (Figley 2002b).
Self-of-the-therapist work in supervision has incorporated approaches that directly address emotionality. Self-of-the-therapist work is an introspective process identifying how the therapist’s personal issues are interacting with therapy (Timm and Blow 1999). Multiple approaches have been purported from the Satir model (Lum 2002), to Bowen theory, to Internal Family Systems theory (Timm and Blow 1999). The commonality underlying these approaches is that the emotionality a therapist may be having in relation to a client stems from past or present life experiences that are being triggered by the client. The goal of supervision then is to help the clinician process through their issues, learn how to use their emotionality in session, or to help them maintain non-reactivity to the client (Timm and Blow 1999). Whereas these approaches to managing self-of-the-therapist issues directly focus on helping supervisees gain insight into their emotions and learn how to use them, it primarily frames the issue as being the therapist’s, rather than framing the reaction as resulting from a systemic interaction. The focus has been almost solely on self-of-the-therapist in relation to family of origin experiences, not accounting for other larger systemic factors that could be at work.
Although compassion fatigue and professional burnout have been identified as the exhaustion of emotions (Figley 2002a), few if any of the approaches to managing these phenomena have even mentioned what a therapist should do in regards to their emotional experiences. In many ways, the emotional reaction of the therapist is implied as abnormal. The implications of the treatments suggested is that compassion fatigue or burnout are just the result of a lack of self-care outside the therapy room, are triggered by stressors the therapist just needs to be desensitized to, or exist because of faulty schemas. When the main reason for compassion fatigue or burnout are related directly to emotional experience, it seems like a deficit that the mental health field has shied away from discussing how to acknowledge, address and manage these emotions without pathologizing them. Unlike supervision methods that are proposed for compassion fatigue and professional burnout, approaches for self-of-the-therapist issues often directly address the emotionality of the clinician (e.g., Lum 2002; Timm and Blow 1999; Wetchler 1999). So far, however, this work has been limited to being applied to family of origin triggers and has not applied to larger systemic influences, or even factors that are present and can be changed. We propose an emotionally-focused inspired approach to supervision for the therapists that are being emotionally impacted by their clinical work, and we will display how to apply this approach using work with long-term clients as an example.
Managing Compassion Fatigue through an Emotionally-Focused Supervision Approach
Emotionally-Focused Therapy (EFT) developed out of the conceptualization that emotions are an inherent and universal human experience that guide behavior and guide change, but are underutilized in therapies (Greenberg and Johnson 1988). Instead of focusing solely on cognition through the process of therapy, EFT evokes and works with the emotion that is tied to any cognitive thought process. EFT is an experiential and systemic perspective that works to understand the context and system wherein an emotional reaction developed and how the present emotional state is related to behavior (Greenberg and Johnson 1988).
The present treatments indicated for compassion fatigue focus on the context within the therapist’s personal life (i.e., their home life and self-care) or focus on correcting the therapist’s experience of emotion through behavioral (Figley 2002b) or cognitive (Pearlman and Saakvitne 1995) therapies. The context wherein the emotionality developed, the therapy room, are not accessed in these approaches. On the other hand, approaches for self-of-the-therapist work have not integrated larger systemic influences into conceptualization of the problem (Timm and Blow 1999). Our approach to supervision addresses self-of-the-therapist issues, compassion fatigue, or professional burnout, incorporating these missing pieces. Although EFT was developed to be used with couples, we believe that the stages as developed can still inspire practices in the supervision setting with an individual clinician.
Supervision related to self-of-the-therapist issues has been approached through a Satir model (Lum 2002), Bowen theory, Experiential Therapy, Internal Family Systems theory (Timm and Blow 1999). Each of these approaches address the emotionality of the therapist in response to the client. These approaches generally identify how the therapist can manage or use those emotions going forward with the client. Hill (1992) identifies the importance of attending to the relational growth of the supervisory relationship through an attachment theory based supervisory process. In this approach, supervisors work with therapists’ attachment style responses to help them work more effectively with their clients. Supervisors act as a secure base for the therapists working to understand and acknowledge their emotionality. We find this to be a crucial parallel process to help supervisees do the same for their clients. It is important for the supervisor to be able to effectively manage and address emotionality in the supervisor-supervisee relationship.
One model of supervision has integrated primary emotions into the supervision of family therapists (Wetchler 1998, 1999). Guided by underlying EFT theory, Wetchler (1998) depicted several techniques for accessing the therapist’s primary emotions. These included accessing the supervisee’s primary emotions directly, hypothesizing about the client’s primary emotions, and relating primary emotions to the therapist’s family of origin experiences. By focusing on primary emotions that the therapist is experiencing, interface issues with a client can be ameliorated. We would like to expand upon this model of supervision to incorporate additional features of EFT that will lend to fully understanding and managing emotionality related to multiple influencing systems. We present and discuss steps 1 through 6 of the EFT model as we apply them to the supervision process for therapist’s working with long-term clients.
Step 1: Delineate Supervision Issues
The first step of EFT is focused on allowing the clients, the couple, to tell their story and identify their perceptions and experiences of the problem (Greenberg and Johnson 1988). Delineating core issues is the prerogative. During this first part of treatment, the therapist is focused on asking questions about the experiences and patterns, the process of the interaction, but not on the content of those interactions. The supervisor who is applying this step in the treatment of compassion fatigue follows the same process. It is this step in supervision where the supervisor will identify that self-of-the-therapist, compassion fatigue, and/or professional burnout are the core issues the supervisee needs to address. Supervisors allow supervisees to discuss and identify what they believe to be the issues they are seeing in treatment, or the issues that supervision is needed for. As with EFT, the supervisor is not concerned with content, any questions given to the supervisee are about the process of interactions with clients, focusing on themes that emerge related to the difficulties the supervisee is experiencing. If the supervisee is experiencing compassion fatigue or burnout, there will be themes of the therapist being frustrated, exhausted, or overwhelmed. For example, the supervisee may identify themes of feeling helpless or maybe even anger with the client. Signs of self-of-the-therapist issues may include the therapist being annoyed with the client, dreading going to session, or spending a significant amount of time thinking about the client or treatment outside of the session. Wetchler (1998) indicates that some therapists are able to take supervision directives and apply them to treatment in spite of their emotional experience, but when a therapist is having a difficult time applying a directive, it can be a clue that the therapist’s own emotionality has become a part of the process of therapy. Heightened emotional expression, or avoidance of supervisor directives are indicators the therapist is experiencing a self-of-the-therapist issue, compassion fatigue, or burnout.
In this type of work, the supervisor’s focus is not on fixing supervisees’ treatment of the client, not on telling them what to do, but instead the supervisor is working with the supervisees’ emotional response to treatment. The core issue is the emotional experiences of supervisees impeding their ability to think clearly about their work, and that the emotional experience may also be affecting their personal life outside of the therapy room. The supervisor avoids focusing on individual traits of the supervisees that are causing the experience, but instead focuses on the systemic interactions and experiences with their clients. The supervisor reflects and validates supervisees’ feelings. For example, the supervisor may respond to a supervisee’s frustration with a lack of clinical progress saying, “It seems that with how treatment is progressing, you’re feeling like you’re not able to make as big a difference as you’d like, like you feel your contribution doesn’t matter. You’re feeling a little stuck, a little hopeless.” It is not an individual deficit of the therapist that causes the experience of compassion fatigue, it is a common outcome for clinicians; having an emotional reaction to one’s work is normal. An alternative response that focused more on the therapist’s deficits might be something like, “It sounds like you’re working too hard for the client”, or “You’re too invested in the client’s outcome.” By the supervisor conceptualizing the development of the compassion fatigue in emotional terms and as a result of a systemic interaction, pathologizing the supervisee is avoided. In responding to self-of-the-therapist issues, the supervisee might say, “It seems that you’re frustrated that this client is responding to you the same way that your mother did growing up and you’re feeling a little stuck on how to change that pattern.” Generally there are identifiable reasons for clinicians’ emotions or reactions, there is generally a theme behind their experiences.
Step 2: Identify the Cycle Where the Conflict is Expressed
The second step of EFT is focusing on the cycles of conflict, and especially the negative interaction cycles (Greenberg and Johnson 1988). This step in treatment is modified for the supervisor, as the supervisor cannot witness the cycle that is involving the emotionality in action because the supervisee’s client is not part of the supervision process, and it is likely related experiences in a much larger system than can be brought to supervision. This step for supervision can be enhanced if the therapist is able to present video or audio recordings of the session. The supervisor will listen for patterns around the experience of compassion fatigue, and then describe the cycle of the experience for the supervisee. The cycle of emotional response to treatment may become evident if the supervisor examines the core issues that lead a supervisee to bring a specific case to supervision. A type of supervision issue may be regularly raised that could be related to the supervisee’s emotional process. Once the theme is identified, the cycle surrounding this feeling should be traced. The difficult part in identifying the cycle is that it can be rooted in a few different systems. The cycle could be rooted in the therapist-client system, it could come from the professional system, the work system, or the therapist’s family system manifesting as self-of-the-therapist issues.
If the issue is rooted in the therapist-client system, the supervisor may notice that the supervisee consistently brings a specific case, or similar cases, to supervision (e.g., clients who are displaying a high level of emotionality regularly, clients who have experienced trauma, or clients who are slow to progress in treatment). Long-term clients are likely to elicit feelings of hopelessness, confusion, or discouragement, or because of the engagement of empathy, any number of sensitive emotions the client was also experiencing. To facilitate the process of understanding the cycle with a particular client, the supervisor can have the therapist bring in information on ongoing client progress assessments. For example, if the therapist employs the Outcome Questionnaire (OQ; Lambert et al. 1996), they could bring in a chart displaying client progress, and writing on it what was going on in the client’s life throughout, and how the therapist felt about treatment during each of those times. The supervisor could say to the supervisee, for example, “It sounds like when the client’s symptoms reoccur, or the client seems to regress in treatment, that you start to feel hopeless and confused. At that time, you have a hard time continuing to ask questions or listen to the client, and instead you go into ‘fix-it’ mode and start giving the client directives.” After the cause of the supervisee’s emotionality has been identified, the next part of the cycle is identifying how the supervisee’s reaction is affecting treatment. “At the same time you’re starting to feel hopeless and frustrated, you notice that the client begins to get quiet in treatment. Maybe they’re feeling helpless themselves and worried they can’t change so they withdrawal from interactions?” The supervisor can question what happens to the supervisee’s client at this point in the cycle. The goal is to understand both sides, and help the therapist recognize both the context of this emotional reaction and its influence.
The issue and the cycle could also be embedded in influences from the larger professional system. As we discussed earlier, interactions with the professional system could lead a clinician to believe that short-term treatment is optimal and possible for all clients. Then, when a client needing long-term treatment is on a supervisee’s caseload it could cause a variety of reactions, including a supervisee feeling frustrated or embarrassed that they are not able to make changes happen more rapidly. Those feelings can transform and present as blaming the client for the lack of progress or even anger toward the client. The supervisor may hear the supervisee say things like, “This client does not want to change, he doesn’t do anything to help himself” or “I think the client has made as much progress as they will ever make, I’ve tried everything.” If the reaction to the client does not seem to be related to the client’s presenting problem, but the longevity of the case, this is a clue the cycle is related to the larger professional systems. The supervisor can reflect the cycle as related to the professional system, “It sounds like you feel frustrated that treatment is taking so long, that usually you have been able to see a more substantial change at this stage in treatment, but with this client not following that pattern you feel hopeless and worry you can’t help them change.” The supervisor can relate these feelings to the supervisee’s expectations for treatment, and where they learned those expectations. Expectations can be traced to readings the therapist has done, trainings the therapist has been to, or colleagues the therapist has worked with.
Work systems can also cause an emotional reaction for a therapist working with a long-term client. A work environment, for example, may not allow a therapist to see a client for a prolonged period of time. Some treatment centers only allow clients to be seen for a maximum of 8 sessions, which places a lot of pressure on a therapist to create change quickly. Not being able to complete treatment in this time period for every client, which is inevitable, can cause a feeling of helplessness or, again, discouragement. Work load expectations may also contribute to a therapist feeling burned out. If a therapist does not have enough time allotted between sessions with clients, it might tax the therapist’s ability to maintain an empathic response throughout the day. If the therapist’s caseload has a lot of long-term clients in need of a high level of emotional engagement, it can be problematic for the therapist’s emotional recovery. The supervisor can frame this cycle to the therapist by saying something like, “This particular client you always have at the end of a long day of therapy. I can see that it is difficult for you to engage the emotionality the client brings to session at this time of the day and that you withdrawal emotionally because you’re so exhausted. You feel stuck and sad because you know the client needs you to be emotionally present, but you don’t know how to after being empathic to others all day.”
From there, the supervisor can explore the supervisee’s needs and feelings, and can validate them. Again, understanding the context the emotion is developing in is crucial for the therapist. It is important for the supervisee to recognize the compassion fatigue, or other emotions experienced, is part of a self-protection process. The compassion fatigue could be a sign of several different things. It could indicate that the therapist is engaging in a pursue-withdrawal pattern with the client, or it could be a sign the therapist is feeling ineffective or helpless. The main goal is to identify where the peaks of the compassion fatigue or burnout are, as they will provide information about the potential emotions experienced by the supervisee.
Step 3: Access Unacknowledged Emotions
Once the cycle has been identified, the focus moves to the emotions experienced by the therapist. The goal for this step of treatment is the “accessing and accepting of unacknowledged feelings underlying interactional positions” (Greenberg and Johnson 1988, p. 88). When the therapist is feeling compassion fatigue, when she or he is feeling exhausted, what else is the therapist feeling? Is the therapist feeling overwhelmed, insecure, embarrassed, afraid, helpless? The therapist may describe his or her emotion as being anger, frustration, or annoyance even, but these emotions are secondary emotions. The supervisor works to identify the primary emotion behind the defensive mechanism.
Emotional expression and experience can be divided into four categories: adaptive primary emotions, secondary emotions, instrumental emotions, and maladaptive primary emotions (Greenberg and Johnson 1988). Secondary emotions are those that while expressed are in the form of defensive coping strategies, meant to protect one’s self, but when expressed can be counterproductive for change. This can include anger, hatred, and revenge. “Secondary responses are the emotional reactions that behaviorists and cognitive behaviorists often claim need to be bypassed or curtailed in therapy” (Greenberg and Johnson 1988, p. 6). Instrumental emotions are those that are meant “to manipulate the responses of others” (p. 7), and maladaptive primary emotions are ones where the emotional response, the biological reaction, has become maladaptive. An instrumental emotion might be one where a person expresses fear to gain comfort from another person, whereas a maladaptive primary emotion could be something like having a fear of intimacy in response to interpersonal trauma. Primary emotions, on the other hand, may not be fully within the consciousness of the individual. They are the more vulnerable emotions a person may feel, and may even be accompanied by physical sensations or vivid images. This can include hurt, fear, and helplessness. “It is only the experience and expression of adaptive primary emotions that convey biologically adaptive information that aids in problem-solving, unified action, and constructive interaction” (p. 6). The therapist experiencing compassion fatigue or professional burnout may be experiencing any of these emotions, and the supervision process will seek to identify the primary emotions and identify their type.
As is the case for therapists working with clients who have experienced trauma, listening to the life stories of the long-term client could incur a feeling of helplessness (Pearlman and Saakvitne 1995). Listening to how life events have created lasting and persistent outcomes can lead to a sense of grief for the therapist recognizing the permanence of the impact of some life events (Pearlman and Saakvitne 1995). Or, the therapist may struggle with what his or her role is in treatment, and what his/her identity is, creating confusion or also grief. A therapist’s loss of hope for making progress can also foster feelings of frustration, despair, or fear of failure (Pearlman and Saakvitne 1995). Furthermore, the therapist may experience feelings of fear if their experiences and the client’s stories lead the therapist to challenge his or her central beliefs about the world, or even treatment (Pearlman and Saakvitne 1995). If working with the long-term client creates a sense of personal responsibility or challenges the therapist’s sense of achievement, feelings of blame or incompetence may arise (Figley 2002b). The therapist may display this is what they’re experiencing through comments including, “I just don’t understand why the client keeps telling me this story, there isn’t anything they can do to change it, we need to move past this.” Or, “The client doesn’t do the homework that I assign them, I don’t think they really want to change.” Experiencing the client’s emotions is also a potential side effect of working with the long-term client if the therapist has projected one’s self to empathize with their experiences. In this case, the therapist may be experiencing the same primary, or secondary, emotions as his or her client. Other “personal costs to the therapist can include depression, despair, and cynicism” or even alienation from professional or personal connections (Pearlman and Saakvitne 1995, pp. 156–157). This list may not be exhaustive, but can provide the supervisor with areas to consider for the source of emotionality in the supervisee. Our list here focuses on the potential primary emotions the therapist may feel, but certainly supervisees will express a variety or secondary emotions to mask these vulnerabilities. The supervisor accesses these emotions the therapist is experiencing in supervision, and focuses on the primary emotions. The supervisor can respond to these statements by identifying the primary emotion for the supervisee, “When the client talks about their trauma I wonder if you’re feeling overwhelmed, that’s a very difficult story to hear. I can see you care about your client a great deal, what are you feeling when you see that pain over and over again? It must hurt you quite a bit.” Or, “I can see that you really want to take your client’s pain away for them, you seem to have a sense of immediacy in fixing this for them. What’s going on for you at those moments you feel that immediacy? I sense you might be feeling helpless when you can’t fix it. It must be scary to see that someone could be hurt that deeply.” It’s a heightening process where the supervisee engages, experiences, and recognizes the emotion while in supervision.
Step 4: Reframe: Victims of the Cycle and Now Allies Against it
By recognizing how the cycle of therapy itself has contributed to the therapist’s emotional experience, the therapist can recognize how this is part of the process, part of a cycle, and that it can be changed. Step 4 of supervision is to focus with the therapist on this reframe, on this understanding of his or her emotionality as part of a cycle and part of a larger context. At this point in treatment, the supervisor focuses the supervisee on the primary emotion she or he feels during treatment, not on blaming the client or focusing on what the client did to elicit the feeling. Impatience with a client’s progress might be reframed as feeling helpless or feeling like a failure. Feeling exhausted by the client’s emotional experience in session might be reframed as feeling overwhelmed or hopeless. The supervisor also reframes the client’s part of the cycle. For example, a client may be feeling overwhelmed with change that is happening in treatment, or may feel fear that they’re letting the therapist down by not changing fast enough. “So what I’m seeing is that when change seems to be going really slow, your client starts to cancel sessions more and that you start to get more directive in subsequent sessions. I wonder if your client starts to get afraid and feels hopeless when change isn’t apparent, and that you see that as a lack of investment and start to feel disrespected, hurt, and worried you can’t help them.” Finally, the supervisor can reframe the supervisee’s emotional reaction as part of the systemic pressures they are facing from either the professional or work community. “Most of the cases on the client load here are short-term cases, you or your colleagues are able to help a client usually within about 10 sessions. I notice that when you have a case that doesn’t follow that blueprint you are more frustrated. Do you feel like you’re failing your client when you can’t help them within 10 sessions? Is it hard for you to go to group supervision and hear your colleague discuss a successful termination and then have to discuss this case that is taking longer than usual? You start to feel like a failure at those times?” The reframe of the cycle and of any secondary emotions are solidified before the supervisor moves forward. The supervisor continues to bring issues back to the cycle where appropriate until the supervisee can recognize and verbalize the cycle her or himself.
Step 5: Promote Identification of Needs to be a More Effective Therapist
Traditionally in EFT, step 5 of treatment is meant to have couples enact the cycle and practice expressing their emotional needs to break the cycle (Greenberg and Johnson 1988). Again, since the client is not involved in the supervision, this step looks a little different in this supervision process. At this step in supervision, the supervisee and supervisor will identify how the emotions that are being experienced point to needs that the supervisee has to maintain her or his emotional health. In this supervision approach the supervisor may have to play a role similar to what the partner traditionally would, and help provide the need to the therapist. This could mean providing resources, identifying evidence that they are effective, or reframing the process for the therapist.
The particular need a therapist has depends on the therapist’s emotional experience. If a therapist is feeling deficient because they could not produce results with the client, the supervisor can work with the supervisee to determine times when they did feel effective or how they could feel effective, whether with this particular client or with others. This could mean refocusing on smaller indications of client progress, and adjusting expectations for the outcomes in long-term treatment. “I hear your worry that you’re not helping the client enough, that change isn’t happening fast enough. I hear your worry that you’re not being ethical by keeping this client in therapy when you’re not sure it’s helping. What do you need at these times? What do you need to feel effective at these times or to know you’re doing the right thing keeping the client in treatment? What evidence do you have that your work is effective? What’s gone well?” If the therapist is feeling pressure to complete treatment in the short-term because of literature they’ve read or educational experiences they have had, the supervisor can provide them with information regarding long-term psychotherapy (e.g., Leichsenring and Rabung 2011). If a supervisee is feeling inferior to other clinicians who only engage in short-term treatment, the supervisor could reframe this as the therapist taking a chance on a client, working with a client where others may have refused to take the case. It could actually be a sign that the therapist is having patience and working with the client at the client’s pace. “Every time your colleague terminates you start to feel worried that you are not an effective therapist, or that you are not doing enough for your clients quickly enough. You start to feel guilty and like a failure. That sense of failure starts to make you become more directive in therapy then trying to prove your worth. I wonder what your clients appreciate about how you work? Let’s identify what benefits your approach to treatment may have despite being different from your colleagues’.”
Other systemic factors, including the therapist’s job characteristics, could also contribute to the experience of compassion fatigue (Maslach et al. 2001). If the therapist’s workload is too great, the time between sessions to recuperate too little, or even expectations from health insurance companies unrealistic, the therapist can reach out to his or her employer to determine what reasonable changes could be made to the therapist’s workload. Perhaps the therapist breaks up a block of time that is set aside for case notes and distributes it throughout the day so there is more time between sessions. In this step, the supervisee will be able to acknowledge their emotional reaction to the cycle, and will be able to identify and pursue means for fulfilling unmet needs.
Step 6: Promote Acceptance
The sixth step in the process of treatment is focused on acceptance. Acceptance of the therapist’s own emotional response, acceptance of the process of long-term treatment, acceptance of the other systemic influences on the therapist, and acceptance that self-of-the-therapist issues, compassion fatigue, and burnout are normal parts of the process. The supervisor can have the therapist practice identifying the sources for self-of-the-therapist issues or compassion fatigue, and acceptance of it. “So when you’re working with a client where progress isn’t happening as quickly as you’d like you start to feel worried by default, you start to put pressure on yourself so you feel effective. What are you starting to recognize about what it means to have this type of case? How can you see your role as different with this case?” Reprocessing past experiences and focusing on the underlying primary emotions can be a powerful means of helping the therapist accept them. “It is very frustrating to you to not be able to do longer treatment with this client because of insurance allowances. Even though it is difficult for you, what reasonable expectations for your own work or that of the client are you starting to have? You’re now able to see that the restrictions aren’t your fault, that you’re not a bad therapist, that you’re not failing your client by working with them despite the constraints.” The emotions should be understood by the therapist at this point, and no longer activating for them or negatively affecting how they work in session.
Self-of-the-therapist issues, compassion fatigue, and professional burnout are not therapist deficits. The emotional exhaustion that a therapist faces in treatment is a normal reaction to an emotionally laden environment. Work with long-term clients is unique in that there are increasingly significant factors in the professional system or the work system that may have the unfortunate circumstance of creating tension for the therapist, and increasing the likelihood of having compassion fatigue or professional burnout. We believe that following the recommendation of other scholars, self-care (Figley 2002a; b) or other treatment approaches (e.g., cognitively-focused approaches; Pearlman and Saakvitne 1995) can be helpful for a therapist. However, taking into account the systemic influences, and the challenges this type of client brings to treatment, we do not believe that the directive of self-care for a supervisee is adequate to resolve the emotionality that is activated for a therapist. We believe that the emotionality of the therapist should be directly accessed in supervision. The emotional experience of the therapist is a valid reaction, not just a result of a lack of self-care, but instead a result of a system interaction.
We suggest an approach for supervision that is inspired by Emotionally Focused Therapy (EFT) and that directly accesses and addresses the emotionality of a clinician. This approach to supervision follows the first six steps of the traditional EFT approach (Greenberg and Johnson 1988) and adapts them for the process of supervision. The primary goal is on identifying the primary emotions that a supervisee is facing. The supervisor works with the therapist to examine what system the therapist’s emotions are related to, how they are a part of a cycle, how they are influencing treatment, and how the therapist can use that experience to identify individual needs to combat compassion fatigue and professional burnout. Although this approach to supervision deals directly with core emotions of the therapist, the primary focus is not to resolve the supervisee’s personal challenges, as is the core goal of therapy. The focus here, although incorporating and addressing emotionality, is to relate it back to how it is interacting with treatment to help therapists work more effectively with their clients. Other approaches to supervision already address these pieces (e.g., Hill 1992; Lum 2002; Timm and Blow 1999; Wetchler 1999), and suggest that it supports therapists’ development and self-esteem to make them better clinicians. Accessing these core emotions may be difficult for some clinicians and supervisors alike, but when it has become a matter of impeding progress with a client, it may be more of an ethical issue not to.
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Soloski, K.L., Deitz, S.L. Managing Emotional Responses in Therapy: An Adapted EFT Supervision Approach. Contemp Fam Ther 38, 361–372 (2016). https://doi.org/10.1007/s10591-016-9392-8