Occupational Vulnerability for Psychologists

This document was prepared by Karen Saakvitne, Ph.D., and the members of the Board of Professional Affairs Advisory Committee on Colleague Assistance (ACCA).

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

An interactive model supports our contention that all psychologists are vulnerable to occupational stress and distress at times in their careers, and may be vulnerable to impairment given the right circumstances. One can think of this vulnerability as a continuum from occupational stress to personal distress to professional impairment. It is our contention that earlier awareness and intervention are in the best interests of psychologists and the public they serve.

Despite a small, but compelling literature on occupational stress for psychologists and other mental health professionals, the topic of vulnerability is not widely addressed within the profession. The prevalence of stigma associated with psychological distress and a misguided belief that psychologists should not be affected by their work, combine to create a "conspiracy of silence" (Pope, 1994) about occupational vulnerability for psychologists. Yet, at the same time, research studies indicate the very real effect of distress and impairment on psychologists (Guy, 1989; Pope, 1987).

Aspects of the Person or Individual Psychologist

As a therapist, each psychologist draws upon his or her unique resources and knowledge, shaped by personal history, life experiences, personality, temperament, biology, and spirituality. These unique personal characteristics represent both strengths and potential areas of vulnerability — by themselves or in interaction with aspects of our work situation. Our strongest protection is our level of self-awareness. Every psychologist is vulnerable; it is up to each of us to identify our specific areas of vulnerability.

Personal History

Psychologists enter their profession for deeply personal reasons. We each choose our areas of specialization, theoretical orientations, clientele and other areas of professional focus for reasons that are influenced by our past and present experiences. We use our own emotional and cognitive responses to the world as tools in our clinical work. The better we understand our own responses and their etiology, the better able we are to use our responses in the best interest of our clients and of the work itself.

As we listen to our clients, we struggle to negotiate between empathy and overidentification and between objectivity and arrogance. Our self-knowledge and openness to our own internal process is the best safeguard against the blinding influence of our own projection or narcissism. We count on many supports, including our personal therapists, colleagues, consultants, supervisors, and teachers (and, in fact, our clients) to help us know ourselves well enough to be good psychotherapists. As we know ourselves, we make decisions about with which clients and modalities we are best suited to work.

Life Circumstances

Life happens to psychologists as it does to everyone else. Over the course of a career, one may face illness, bereavement, traumatic experiences, marriages or divorces (partnerships or separations), birth or adoption of children, family tragedies, family triumphs. Each of these events will affect us in our work as well and will interact with the particular issues and life events of our clients. Thus, we can become more vulnerable to occupational stress at certain times. This subject, long taboo (with a few notable exceptions including Frieda Fromm-Reichmann), is thankfully becoming more common.

Some of us enter the field with known vulnerabilities, physical or psychological. These vulnerabilities are often also sources of strength, empathy and understanding. However, they need to be addressed. Just as a construction worker with a bad back must wear a back brace, so a therapist with a vulnerability to depression must shore up his or her support system and monitor his or her need for psychotherapy or medication as needed.

Aspects of the Situation (Work)

Cultural and Social Context

One aspect of our work situation includes the cultural and social context of this work, which at this time includes the present health care system and climate. As psychologists, we face increased challenges to our work (including decreasing revenue and autonomy of practice coupled with increasing demands for documentation, justification and “collaboration”). The stress of our work multiplies as the financial rewards decrease and bureaucratic hassles increase. Implicit in these difficulties is the cultural devaluation of the work we do and the clients whom we treat. Those who receive psychological treatment are stigmatized in this culture, and thus those who provide the treatment are devalued.

Psychotherapy Relationship

Another situational factor that contributes to our vulnerability to occupational stress is the nature of our work as professional psychologists. This work often involves connecting with clients who are in personal distress, sometimes in great psychic pain. We listen to clients’ accounts of painful life circumstances and events that may include stories of loss, traumatization, neglect, isolation and despair. They may include graphic accounts of brutality, horror, and tragedy. They may include situations that closely parallel the therapist’s own life, past or present. As clients describe their emotions and experiences, we often feel a range of sometimes intense emotions, and may have visceral or physical reactions. The nature of psychotherapy is such that our relationship with our clients occurs at both a conscious and unconscious level, and we may thus experience surprising or disturbing reactions that we do not at first understand.

Role

Further, we hold a complex and demanding role in this work. Requirements of confidentiality, ethical boundaries, clinical responsibility and empathic attunement create role-demands that require stamina, clarity, and integrity. These role-demands are varied and may shift rapidly as we manage both the relational and transference demands and the business and legal demands of our work. Therapeutic relationships are uniquely intimate and uniquely bounded and many clinicians find themselves unprepared for and inadequately supported in the difficult challenges inherent in these relationships.

Work Setting

Our situation also includes the specifics of our practice and work setting. The particular stresses and the degree of support that we experience in our particular work setting with our particular work responsibilities and clientele influence our vulnerability to occupational stress. The amount of control we have over the particulars of our work is also a relevant factor. The extent to which our work as psychologists is valued and supported by the systems within which we work affects our professional esteem and as well as the amount of energy we must expend in defending or justifying our work. Another significant factor is isolation. Many psychologists practice in relative isolation, either in private practice, or as the only psychologist in a multidisciplinary setting. Many psychologists have insufficient opportunities for formal and informal communication with colleagues about their work. The requirements of confidentiality and the uniquely private nature of the work further exacerbate this isolation and contribute to the stress.

Universality of Vulnerability

Just as everyone in a construction site must wear a hardhat, everyone working in a mental health setting needs to attend to issues of occupational vulnerability and self-care. All psychologists are vulnerable to occupational stress. Particular events in either our work lives (situation) or our personal lives (person) can dramatically increase our vulnerability. There is no shame in acknowledging our vulnerability, but there is danger in ignoring or denying it.

We need to address issues of therapist vulnerability and occupational stress starting in our training programs, and integrate this awareness into our daily routines and practice settings. See the ACCA Fact Sheet on Professional Health and Well-being for Psychologists for more information.

Conclusion

This discussion of occupational vulnerability is based on a developmental, adaptationbased model of distress rather than a pathology-based model. A psychologist does not have to be "sick" to be in distress. Symptoms and illness can reflect adaptations to stress.

The implications of this discussion are clear: We need actively to tend to the psychological and emotional health of psychologists who are employed in the profession of treating clients. The first step is to recognize and define our vulnerability.

The following material is adapted from Transforming the Pain: A Workbook on Vicarious Traumatization (Saakvitne, et al., 1996). The worksheet below invites you to consider the contributing factors to your own occupational stress.

Contributing Factors for Occupational Stress

Nature of the Work

___ How much choice and control do I have over my work?

___ Is my work short-term, crisis or long-term?

___ Am I doing the kind of work that I like? For which I am well-suited? At which I feel competent and valued?

___ Does this work match my values and beliefs?

Nature of the Workplace

___ Do I have enough organizational support?

___ Do I have collegial support?

___ Do I get enough helpful supervision?

___ Other workplace factors?

Nature of the Clientele

___ With what clinical populations do I work?

___ How many clients do I see each day? Each week?

___ Is there balance and variety in my caseload and work?

___ Are there certain clients with whom I especially enjoy working? Why?

___ With which clients do I struggle most? Why?

___ Other client-related factors?

Nature of the Person of the Helper

___ Is my training appropriate for my work?

___ What are my current life stressors and support?

___ What is my relevant life history?

___ What are my familiar coping strategies?

___ What are my emotional style and vulnerabilities?

___ How is the fit between myself and my work?

___ Other personal factors?

Nature of Social/Cultural/Political Context

___ How am I impacted by social obstacles to the work (e.g., $ cuts, denial)?

___ How does the community respond to the work my agency and I are doing?

___ How does the community view the population I serve?

___ Other social/cultural/political factors?

References

Guy, J.D. (1987). The Personal Life of the Psychotherapist. New York, NY: John Wiley and Sons.

Pope, K. S. (1987). Preventing therapist patient sexual intimacy: Therapy for a therapist at risk. Professional Psychology: Research & Practice, 18(6), 624-628.

Pope, K.S. (1994). Sexual Involvement with Therapists: Patient Assessment, Subsequent Therapy, Forensics. Washington, DC: American Psychological Association.

Saakvitne, K. et al. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. New York, NY: Norton.