So, Now What?

The Unseen Struggle: Compassion Fatigue in Mental Health Clinicians

• angela tam

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Therapist burnout is a complex issue that requires more than just sabbaticals or vacations to address. Both systemic problems in the mental health field and our internal psychological patterns contribute to burnout, requiring dedicated inner work alongside traditional self-care practices.

• Systemic issues contributing to burnout include low pay, high client loads, decreasing insurance reimbursements, and commodification of mental health services
• BIPOC and marginalized therapists face additional "representation tax" as role models and advocates for their communities
• Through an Internal Family Systems lens, several internal "parts" often contribute to therapist burnout
• True healing comes from building relationships with these parts rather than trying to change or exile them
• Operating from "Self-energy" allows therapists to witness suffering without absorbing it and balance their needs with clients'




Speaker 1:

Hey, welcome back to. So Now, what Podcast. I'm your host, angela Tam, and I'm continuing on this mini-series made for my fellow mental health clinicians. If you have been working with clients for a while, you might feel a little burned out, and if you haven't been working with clients for a while, you probably hear this a lot in the field. With therapist burnout, therapist fatigue, compassion fatigue. That is something that I wanted to address today, and I want to talk about how sabbaticals, vacations and rest isn't simply enough to prevent or help with therapist burnout, because therapist burnout is a more complicated, bigger issue. That doesn't just come from taking a step back and breaking free of your normal everyday routines, but it comes from that doing practicing rest, but also doing some inner work in conjunction with that.

Speaker 1:

I want to first dive into some of the issues that we face systemically as therapists. First of all, therapist burnout could come from a lot of different origins, and some of which are dysfunctional, harmful work environments, low pay, low mentorship, high performance expectations, and the reality is that, systemically, our work is not valued and it's commodified, and when things are commodified, things are set at a certain rate that institutions deem to be fair to them, not fair to us or what is actually sustainable to us, but what is fair to them, and that means increasing their bottom line. So a lot of things that I'm noticing is that insurance carriers are reimbursing people at a lower starting rate every year and companies like Headway and Alma, who are collective contracting with a lot of therapists and getting a group rate and then taking a cut of that, their rate that they're proposing to new therapists are decreasing every year and the rate of increase pay increases are decreasing every year too, and so what I noticed is that a lot of people who are working with insurance or with EAPs or with companies like Headway and Alma are having to see 30, 40 clients a week in order to pay bills and to pay back loans and to just earn a living wage, which is extremely unrealistic, even if you have all the boundaries up and a modality that supports sustainable work. I really can see how, in this case, oppressive structures and leadership, who are really greedy for the bottom line, who are having CEOs be paid millions of dollars while insurance healthcare providers are being paid very little, are bearing the brunt of that, and so oppressive structures normalize burnout and they see it as personal failure rather than systemic failure. And then BIPOC therapists or therapists we really internalize that. We see that is just a reality, that's just the way it is and we should just accept that and just work as much as we can to pay the bills. And that makes so much sense to me. But at the same time, the acknowledgement here is that the burden is on the healthcare providers to work more and not less, and then our quality of work decreases as a result.

Speaker 1:

Another thing that is contributing to burnout is especially for people who are BIPOC or therapists, who hold marginalized identities that are similar to our clients. We hold an extra representation tax for being the role model, the bridge, the advocate for those who share our identities. Maybe you work with refugee families and you are a child of refugees yourself. Like myself, my parents were born and raised in Vietnam and escaped during the war, and for me, I have parts of me that feel like I need to hold space and be the voice for folks who are refugees too, and to do work around building more content, more educational material, around what it's like to be a part of this population, to verbalize the sufferings that we hold and how it impacts our daily life, what we're talking about today. Those are the different things that can contribute to burnout. I want to focus on how our response to those things can contribute to the burnout because, realistically, we're really limited in how we can shift and alter systemic oppression through our activism. And activism is powerful and I believe that part of our role is to find how we fit into activism and, at the same time, how can we respond in a way that builds capacity versus taking away capacity from our daily life. Some of the things that I want to talk about today is how we can better respond in our nervous system to these external oppressive variables.

Speaker 1:

First I want to dive in by talking about my deep cultural programming and how I was programmed as a therapist and as a person that uniquely contributes to how burnout might look like in my life For me and my Asian family circle, and this is just only applicable to my micro family and I might have some generalizations to macro culture in general. But I just want to speak into my personal experience. Something that I was modeled to show in my very patriarchal traditional home, where my mother was serving my dad as a person who had lesser status, is that she would wait on him, hand and feet, she would hold space for him, she would jump up and do things even before she was asked. And if she was asked to do something, she would do it without questioning, even if it was asked in an extremely rude way. That was the messaging in my family, and if you didn't do it, then you were a bad wife, you were a bad daughter.

Speaker 1:

Obedience means love, means obedience, and obedience means self-sacrifice. And also, to love your family and to be a part of the collective means that you need to sacrifice some of your needs, and not even be aware of your needs, in order to make other people happy, and that's. I just want to give an oversimplified explanation of how my family structure went, and so for me, I was not asked to question that narrative and for me, that bled into how I related to other people in my life, like my friends or my family members and all my partner. I had to do a lot of deprogramming work to get in touch with my needs and get in touch with my feelings and get in touch with my desires, so that I wouldn't be self-sacrificing to allow myself to hold other people's needs in tandem with my needs. And so, before I was doing that work, the internal work of really getting in touch with myself and my inner world.

Speaker 1:

I did find myself really burnt out. I did find myself extremely just, tired and exhausted, perpetually in a state of perpetual self-sacrifice, and, for me, I found myself extremely resentful towards my loved ones, even though they didn't ask me to do what I did. I also was over-responsible and felt like I needed to take on other people's pain without drawing any boundaries, because I thought that what it meant to love others and to serve others was to just lay down my own needs in order to jump to serve others. And that's what I was taught as an evangelical Christian at that time too. The narrative is to lay down one's life in order to serve the others, and I took that literally. I don't think that it was meant to be taken literally, but I really did take that literally, and I ended up having people around me that needed me, and it felt good to be around because I could help them.

Speaker 1:

And I didn't realize that that was what my relationships eventually revolved around, which was a need-based relationship, and whenever people stopped needing me, I just felt like I wasn't. I felt uncomfortable with that. I felt like I couldn't. If I couldn't contribute in a relationship. Then it just felt like I couldn't show up period because my worth was so tied to showing up and being helpful. And so for me, I did go into an internalized despair or identity crisis around how my relationships looked like and I had to reevaluate all my friendships to see if I was really in it because I felt like I could be me, or if I was in it because the part of me that needed to help and found importance out of helping was leading it. And if I were to really break that down even further.

Speaker 1:

I think that as a therapist or clinician and as a person, I did some work in general with my therapist. It wasn't until I found internal family systems therapy that I could really verbalize and articulate this. I knew I was doing this work without realizing that I was doing this work. I'm going to share some of my perspectives from an internal family systems lens, and maybe this will make sense in how it shows up in the therapy relationship if it was left unchecked. So, from an internal family systems perspective, there's a belief that we have different parts of us that are controlling the switchboard. These different parts are all good parts that have misguided protective strategies that don't really take into account thriving, but really they're only concerned about you surviving and they're driven solely by fear of vulnerable parts or exiles taking over the system and causing chaos or turmoil. And I'll give you some examples to see if this makes sense and maybe I could drop back to how this shows up burnout-wise for therapists.

Speaker 1:

A good kid Like, in general, I was seen by a lot of my aunties and uncles as someone who was really mature, someone who had all together, someone who was like really just considerate and kind. But internally it felt like a really different experience. Internally, like I said before, I was exhausted for being hypervigilant and watching out for other people's needs and I felt responsible for helping my family and helping others and I found my worth through that and also I found myself feeling pretty resentful for them not helping themselves and me having to jump in for them. And if I tie that in into an internal family system lens, there is a part of me or us that can be like the first responder part. It over responds by being on it, it jumps at the opportunity to hold space. These are the behaviors associated with each part because, remember, on that switchboard in our hearts and brains. We have different parts that show up and they have their own personalities. And this first part is the first responder that sees every unaddressed need as urgent and it sees themselves as responsible for taking care of other people's needs.

Speaker 1:

Another part that contributes to therapist burnout could be a watchdog for whether or not you're being good enough, and this is, I think, one of the voices for me that is pretty active or was pretty active, active or was pretty active, which is it's like a monitor part to monitor my assessment of whether or not I'm being kind enough, responsible enough, considerate enough or connected enough. It has high perfectionistic standards for how we need to respond to our clients and how they shouldn't be left suffering or should be left in a worse position that they came in. Another part that's used to be on for me is the attunement scanner, and this part constantly watches out for emotional shifts or predicts escalation or distress and watches for body language changes and is triggered when it notices signs of distress in the other person. It works with the first responder part so it doesn't shift into more distress. And the last part that's really big for me that contributes to therapist burnout is the internal suppressor. It silences my own needs, feelings and fatigue signals so that I can focus on remaining outward and helpful to others. It believes that having needs and expressing it is dangerous and it believes that it's not good to do anything about that fatigue except to keep pushing forward, and there's no choice otherwise to not push forward.

Speaker 1:

And the different fears or the vulnerable parts underneath that it's protecting are all different. So there's different examples that I'll give about vulnerable parts underneath and these protectors that I just listed work really hard to not cause me to feel out of control If I miss something important and I'm not attuning to someone. It helps me not to feel like a shitty therapist, because I'm not really quote-unquote doing a good enough job and if I don't carry their pain, if I don't carry their pain, they'll be all alone and be re-traumatized, and so it gives me a vulnerable feeling of not doing the best I could and not carrying their pain and re-traumatizing them and therefore causing me to feel shitty as a therapist. So that is another vulnerable part feeling guilty or feeling ashamed, feeling bad because I did something wrong or didn't do something enough in a good enough way. And that protective system the first responders, the watchdog, the attunement scanner, the internal suppressor. They all protect me from feeling all these bad, shameful feelings underneath.

Speaker 1:

Part of this work is recognizing who the players are on the switchboard and possibly just guessing what. They're protecting me from feeling underneath and working with that exile, working with that vulnerable feeling. And so part of my care plan for how I do this inner work, of really working through my burnout if I sense even a little bit of compassion, fatigue or a little bit of tiredness before it feels exhausting is that I check my parts. I start doing a check to see okay, who is here right now, who's working extra hard in my sessions, and I try to get to know these players and just try to externalize these voices so that I could just take them as what they are and not bring additional meaning to it. And so for me and my encouragement to you and if you're listening to this, as a seasoned therapist or a beginner's therapist, if you are feeling some burnout, just write down some of the literal reasons.

Speaker 1:

The superficial reasons you might see might be contributing to it. You could say I'm seeing too many clients or I don't have enough time to take care of myself, or I'm working long hours and I'm a parent, or I am not able to get enough hobby time, and maybe that's a reason that you can guess and start from there, start to list off the superficial reasons and then start to notice what patterns there are underneath, after every session or at the end of the day. So after every session we notice, oh, I was extra worried about this particular client and I can't stop thinking about this client afterwards. Or, oh, this client gave me really bad feedback today that I wasn't helping them, that what I was doing wasn't supportive, and I can't get that off my mind. I can't stop thinking about how I could have done things differently. Or another thing might be that you might be struggling with something outside of work. You might be going through a divorce, maybe it's a new health diagnosis, like a chronic disease or autoimmune disease. Or your kids are struggling in school, or they're going through their different stages of development and you are having trouble juggling their needs with your needs and your client's needs.

Speaker 1:

Write it all down. Just write a brain dump of things that you might notice that might be taking you away from your centeredness, your being anchored from your centeredness, you're being anchored, you're being compassionate, you're being curious. And write it all down and just notice. Also if you see patterns or behaviors that you are doing in response to those situations, so notice if there's a response to fight, flight, be, flee, fawn, shut down, dissociate. Just notice all these responses and they might not be as clear-cut. So there might be a part of you that wants to fight it. Okay, I'm just going to go head on with it. Or there's might be another part of you that just want to switch jobs and I could just work at Trader Joe's and get my W-2s and get health insurance. That would be amazing and just have predictability in my life and not actually have to think about work after my work is done, after I clock out. Maybe that feels really good.

Speaker 1:

Just pay attention to your stress responses and just notice what you tend to gravitate towards. Do you gravitate towards dissociation, to shut down, to ignore, to flee, to fight, to fawn? Maybe you're like, okay, whatever my clients want, whatever my kids want, I'm just going to do it without questioning, because it's the road that's less resistant and it's less work in the short term. And just notice all those things and I encourage you to write it down and just notice that all these stress responses are parts of you that are really trying to strategize and keep you in a state of survival. Now, if we were to move out of a state of survival into a state of thriving, then we would have to do a lot of work with these stress responses so that they can rest and allow you to practice self-leadership instead of for them to take over. And part of doing that means to be grounded in your what we would call higher self, which is and it's not a part of you, but it's your core and it's the most authentic version of you that is grounded and that is calm, curious, creative, authentic, hopeful, has capacity, is not touched by.

Speaker 1:

And the metaphor for self-energy is that you are a calm pilot in a time of turbulence, where you just notice there's so much turbulence on the airplane but you're able to be really calm. Or your self-energy is like a lighthouse. Or self-energy is like a lighthouse when there's a storm, the lighthouse keeps going with its light shining and it guides faraway ships into safe harbor. Or another metaphor for self-energy is that orchestra and the conductor metaphor, where there's a big orchestra made up of many different instruments and the conductor is not playing an instrument but is leading all the instrument players to be synchronized, to be in harmony with each other, to not take over, not have one instrument necessarily take over or aka a stress response take over, but to have all your parts be in harmony with each other so that your higher self, or your authentic self, could really be leading.

Speaker 1:

And when we think of how this plays out in terms of clinically, one of the things that your self-energy may say as a therapist is suffering is a part of the human experience. It can be witnessed and supported without being absorbed by anyone. I can witness it as a therapist without walking away with residual feelings of sadness and anxiety. Another thing that your inner self or higher self would say as a therapist is every person has inner resources, even if they're not accessible. I can borrow my nervous system for the client to use during our session so they could tap into my self-energy, and there can be enough self-energy for both of us to share into and enjoy. It isn't a zero-sum game. Another thing that your self-energy might say is sometimes the client can be worse off than they started in session, and it doesn't mean that I'm a bad therapist, but it means that I can learn something about how their nervous system works. If they leave triggered, I can trust that they have some resources to bring themselves back to equilibrium, even if it takes a while. Another thing that they can say is I can listen to my parts and their needs while holding in tandem the needs of my clients. There's no timeline to healing, no pressure to alleviate the pain of my clients. Even if my client comes with urgent demands, I can sit and be centered in myself without giving in to the demands, but fully witnessing them. We are not the source of our clients' healing, but we can be their safe and steady presence.

Speaker 1:

Possible to feel hopeful for a different future, even if there are repeated exposures to harm. Future, even if there are repeated exposures to harm, and the last thing that your self-energy might say is our own well-being is just as important, if not more important, than the client, and it's part of collective healing. How do we get there? How do we embrace these truths, these notes of inner wisdom? Notice internal messages or voices that come up when a client says or does something that indicates they're in distress or pain. Write down these messages. Maybe some examples are. I'm here to help you. I'm going to try to be useful.

Speaker 1:

I feel pressure to lift them up out of their suffering or, oh my gosh, they're not going to be okay unless I do something about this and notice behaviors that you do or impulses that you have. Some examples are the impulse to problem solve, to say something positive, to share a note of gratefulness, to express empathy and understanding, to tune in more, reflect back, share a wise nugget and then identify fear behind those behaviors and messages. Maybe there's a fear of abandoning them, fear of missing something important, fear of failing them, fear of being seen as someone who's cold or detached, a fear of being powerless or helpless, a fear of being a bad therapist. And then the last part is to be in relationship with all the primary voices and messages and fearful voices the exiles. Be in relationship with them. This is where I think IFS differs from CBT or other forms of therapy, and maybe there's some similarities too.

Speaker 1:

But being in relationship with all these voices means really accepting them, not trying to change them, not trying to reframe them, not trying to exile them even further by saying it's okay to frame the narrative and change the narrative, but really accept their narratives. It doesn't mean that you're permissive, it doesn't mean that you just allow them to do whatever they want to do. But when you're accepting these narratives and accepting these voices, you're really witnessing them, showing them love, warmth, curiosity and understanding to them. Warmth, curiosity and understanding them as understanding to them and some would even go the extra mile and set up an altar for them in your home, printing out their messages and fears related to their messages, and lighting a candle. And also building a relationship with them means to actually get to know them as if they're other human beings. Each voice has their own distinct personality, behaviors and impulses, and just parsing it out, to get to know them and externalizing them so that there's some distance between you and them, between you and them.

Speaker 1:

This is something that I love to do with other therapists. I love to do this work, to see and go through their inner world with them and how it shows up as a therapist, and I feel like me, as a therapist, can uniquely do that with other therapists because I've been in the field for since 2013,. So 12 plus years. I'm going on to my 13th year, 2013,. So 12 plus years. I'm going on to my 13th year, and I really understand the gamut of emotions that come with being a therapist, whether it's seasoned or beginner, and all the things that might creep up related to self-doubt, imposter syndrome, feeling of inadequate or just even general loneliness that contributes to burnout too, and I can work with you on helping you end sessions on time, to being mindful of your policies or your boundaries within your practice and taking a look at the flow of your work to see if there's anything that is too complicated in your practice, that would be useful to simplify, or anything that might be taking away from your energy we can go through and together in our consultations together.

Speaker 1:

So that is my invitation to you and I will share a link to schedule a free one-on-one with me, as you can work in your schedule and I'd love to do that with you and there's no strings attached. And if you do decide to work with me, it is a six-month commitment to weekly sessions and it's something that we can do together really intimately. And you have access to me with unlimited texting support and weekly one-on-one Zoom sessions, and you'll have access to a Slack channel that I'm creating right now to help with resourcing asynchronously creating right now to help with resourcing asynchronously. If this is appealing to you, feel free to click that link in my show notes and we'll get connected. Take care. Bye.