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 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 work loads, one of the causes for burnout was low social support, particularly low coworker 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 codependent/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.
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Smullens, S. (2012, Summer). Self-care and avoiding burnout. NASW Private Practice Section Connection, Summer 2012. http://www.sarakaysmullens.com/media/2012PrivatePracticeNL-NASW.pdf.
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.