Learning Objectives

This is an intermediate course. Upon completing this course, mental health professionals will be able to:

• Discuss the ethical imperative of psychotherapist self-care.
• Explain how a professional’s self-care translates into improved service to the public.
• List three research-supported methods of maintaining ethical boundaries.

This is the first course in a three-part series. Portions of this course are adapted from the book, Leaving It at the Office: A Guide to Psychotherapist Self-Care, © 2018 by John C. Norcross and Gary R. VandenBos and reprinted by arrangement with Guilford Press.

The information in this course is based on the most accurate information available to the authors at the time of writing. Self-care research and practice grow continuously, and new information may emerge that supersedes these course materials. This course will provide clinicians with an understanding of self-care and equip them to experiment with additional self-care methods. Doing so may provoke novel feelings or unsatisfying results for some readers. There are no known severe risks of engaging in clinician self-care.

Note: This first course is the foundation for all three of the courses in the self-care series. We strongly recommend that it be studied first followed by the next two courses in sequential order. The second course, Therapist Self-Care: Personal Relationships, Cognitions, and Behaviors covers self-care at the office as well as away from the office. The third course, Mindful Self-Care: Your Internal and External Environments, offers a wide range of mindfulness-related practices for the self-care of the therapist.  We hope that your spirit and practice will be touched as you study the information provided here and that these self-care strategies will awaken and direct your sensitivities to your personal and professional identity as a psychotherapist.

Outline

• Introduction
• Valuing the Person of the Psychotherapist
  • Convergence of Research and Practice
  • Confluence of Individual and Environment
  • Running Against the Tide
  • Research on Psychotherapist Self-Care
• Self-Care as Ethical Imperative
  • The Paradoxes of Self-Care
  • Begin with Self-Awareness and Self-Monitoring
  • Building on Your Self-Care Strengths
  • Making Self-Care a Priority
  • Valuing You
  • Self-Care Checklist
• Setting Ethical Boundaries
  • Setting Boundaries at the Office
    • Defining the Role of the Psychotherapist
    • Defining the Role of the Client
    • Defining the Boundaries of Treatment
    • Defining Relationships with Colleagues and Staff
    • Defining Boundaries with Family and Friends
  • Setting Boundaries Away from the Office
    • The Psychotherapist Outside the Office
    • Clients Outside the Office
    • Colleagues Outside the Office
• In Closing
  • Self-Care Checklist
• References

Introduction

Practicing psychotherapy can be demanding and grueling. This can result in a state of elevated stress that affects the quality of one’s clinical care as it diminishes the ability to maintain a focus on clients’ needs in empathic relationships. Psychotherapist self-care thus begins with valuing the person of the psychotherapist and adhering to an ethical imperative of caring for oneself. Self-care is a personal challenge and professional imperative that every mental health professional – literally, everyone – must consciously confront.

Those interested in the psychotherapist as a person have two sources of literature available to them. The first is the periodic manuscript penned by practicing clinicians on their professional and personal experiences. The second source is the formal research article presenting results of a group of responding therapists on a specific topic. The research on psychotherapist self-care has not progressed to the level that many randomized clinical trials have been conducted. Therefore, we have aimed for the middle ground to draw on the advantages of the captivating narrative and the nomothetic wisdom of aggregate research.We synthesize clinical wisdom, research literature and therapist experience by interweaving throughout the course the theoretical literature, survey data, empirical research, autobiographical material and personal disclosures from mental health professionals of diverse genders, orientations and ethnicities.

This course summarizes the research on how self-care improves service to the public and enhances contributions to the profession. It considers several paradoxes of self-care for mental health professionals and explores in detail the ethics of self-care as described in the ethical codes of mental health professions. Following this introduction, the course focuses on making self-care an ethical and personal priority by developing self-awareness, self-monitoring and setting ethical boundaries both at the office and away from the office. Examples of personal replenishment are described as well as research in this area and the practices of master therapists. The course concludes with a practical self-care checklist.

Valuing the Person of the Psychotherapist

“There is only one recipe – to care a great deal for the cookery.”

– Henry James

One fine morning, a psychotherapist meets a fellow psychotherapist on the street. The first psychotherapist says to the other, “You are fine. How am I?” That apocryphal tale highlights the ironic dilemma and the universal challenge for mental health professionals: We are so busy tending to others that we frequently neglect our own self-care.

Mental health professionals, by definition, study and modify human behavior. That is, we study and modify other humans. Psychological principles, methods, and research are rarely brought to bear on psychotherapists ourselves, with the probable exception of our unsolicited attempts to diagnose one another (Norcross, 2000). Carl Rogers (1961) admitted that “I have always been better at caring and looking after others than caring for myself.”

Although understandable and explicable on many levels, this paucity of systematic study on psychotherapists’ self-care is unsettling indeed. It is certainly less threatening, individually and collectively, to look outward rather than inward. Anna Freud once made the telling observation that becoming a psychotherapist was one of the most sophisticated defense mechanisms, granting us an aura of control and superiority and avoiding personal evaluation ourselves. In any case, this state of affairs strikes us as backward: We should be studying ourselves and then others.

Consider that psychotherapists are among the most highly trained and experienced agents of change. Yet, compared with the tens of thousands of studies on how our patients change, we know relatively little (at least publicly) about how we cope with our own distress or change our own behavior or struggle with the hazards of our craft. The tendency to view psychotherapists as not having lives outside the consulting room apparently afflicts us as well as our clients.

This course – and psychotherapist self-care – start with valuing the person of the psychotherapist.

Convergence of Research and Practice

The person of the psychotherapist is inextricably intertwined with treatment success. We know, scientifically and clinically, that the individual practitioner and the therapeutic relationship contribute to outcome as much as, and probably more than, the particular treatment method. So-called therapist effects are large and frequently exceed treatment effects (Castonguay & Hill, 2017; Wampold & Imel, 2015). Meta-analyses of therapist effects in psychotherapy outcome average 5% to 9% (Crits-Christoph et al., 1991; Wampold & Imel, 2015).

Two huge studies estimated the variability of outcomes attributable to therapists in actual practice settings, one in the United States involving 6,146 patients and 581 therapists (Wampold & Brown, 2005) and the other in the United Kingdom with 10,786 patients and 119 therapists (Saxon & Barkham, 2012). Five to seven percent of outcome was due to therapist effects; about 0% due to the specific treatment method. Despite impressive attempts to experimentally render individual practitioners as controlled variables, it is simply not possible to mask the person and the contribution of the therapist.

That contribution of the individual therapist also entails the creation of a facilitative relationship with a patient. The therapeutic relationship, as every half-conscious practitioner knows in her bones, is the indispensable soil of the treatment enterprise. Best statistical estimates are that the therapeutic relationship, including empathy, collaboration, the alliance, and so on, accounts for approximately 12% of psychotherapy success (and failure; Norcross & Lambert, 2018). That rivals or exceeds the proportion of outcome attributable to the particular treatment method.

Suppose we asked a neutral scientific panel from outside the field to review the corpus of psychotherapy research to determine what is the most powerful phenomenon we should be studying, practicing, and teaching. That panel (Henry, 1998, p. 128) “would find the answer obvious, and empirically validated. As a general trend across studies, the largest chunk of outcome variance not attributable to preexisting patient characteristics involves individual therapist differences and the emergent therapeutic relationship between patient and therapist, regardless of technique or school of therapy.” That’s the main thrust of five decades of empirical research.

Here is a quick clinical exemplar to drive the point home. It derives from a thought experiment we use in our clinical workshops. We ask participants, “What accounts for the success of psychotherapy?” And then we ask, “What accounts for the success of your personal therapy?” The prototypical answer is “Many things account for success, including the patient, the therapist, their relationship, the treatment method, and the context.” But when pressed, approximately 90% will answer “the relationship.”

Their responses dovetail perfectly with the hundreds of published studies that have asked clients to describe what was helpful in their psychotherapy. Patients routinely identify the therapeutic relationship. Clients do not emphasize the effectiveness of particular techniques or methods; instead, they primarily attribute the effectiveness of their treatment to the relationship with their therapists (Elliott & James, 1989; Levitt et al., 2016).

Consider the clients’ perspectives on the helpful aspects of their treatment in the classic National Institute of Mental Health Collaborative Treatment Study of Depression. Even among patients receiving manualized treatments in a large research study, the most common responses fell into the categories of “My therapist helped” (41%) and “I learned something new” (36%). At post-treatment, fully 32% of the patients receiving placebo plus clinical management wrote that the most helpful part of their “treatment” was their therapists (Gershefski et al., 1996).

As a final illustration, we would point to studies on the most informed consumers of psychotherapy – psychotherapists themselves. In three of our replicated studies in the United States and the United Kingdom, hundreds of psychotherapists reflected on their own psychotherapy experiences and nominated lasting lessons they acquired concerning the practice of psychotherapy (Bike et al., 2009; Norcross et al., 1988b; Norcross et al., 1992). The most frequent responses all concerned the interpersonal relationships and dynamics of psychotherapy: the centrality of warmth, empathy, reliability, and the personal relationship; the importance of transference and countertransference; the inevitable humanness of the therapist; and the need for more patience in psychotherapy. Conversely, a review of published studies that identified covariates of harmful therapies used by mental health professionals concluded that the harm was typically attributed to distant and rigid therapists, emotionally seductive therapists, and poor patient-therapist matches (Orlinsky et al., 2005).

All of this is to say that science and practice impressively converge on the conclusion that the person of the clinician is a locus of successful psychotherapy. It is neither grandiosity nor self-preoccupation that leads us to psychotherapist self-care; it is the incontrovertible science and practice that demands we pursue self-care.

A professional’s self-care translates into improved service to the public, but the particular pathways have not been sufficiently identified. Does self-care work through reducing stress, increasing life satisfaction, providing social support, preventing burnout, or all these mechanisms (Rupert & Dorociak, 2019)? Less-stressed mental health professionals prove more emotionally available, technically flexible, and interpersonally responsive to patients. Is that the primary pathway? Or is it that mental health professionals sufficiently attending to their physical care – sleep, hydration, exercise, and the like – are more effective than sleep-deprived and poorly-nourished colleagues? Future controlled research will probably disentangle and prioritize the multiple pathways.

Want to improve the effectiveness of psychotherapy? Then follow the evidence; the evidence that insists we train and nourish the individual practitioner.

Confluence of Individual and Environment

A leitmotif of this series of courses is the interdependence of the person and the environment in determining effective self-care. The self-care and burnout fields have been polarized into rival camps. One camp focuses on the individual’s deficits – the “fault, dear Brutus, is in ourselves” advocates – and correspondingly recommends individualistic solutions to self-care. The other camp emphasizes systemic and organizational pressures – the “impossible profession with inhumane demands” advocates – and naturally recommends environmental and social solutions.

In this course, we value both camps and adopt an interactional perspective that recognizes the reciprocal confluence of person-in-the-environment. The self is always in a system.

When conceptualizing the self-in-a-system, we repeatedly point to the unique motives, family of origins, and underlying psychodynamics of mental health professionals. What drives a person to concern herself with the dark side of the human psyche? What is it that compels certain people to elect to help those who are suffering, wounded, or dysfunctional? Assuredly they are a “special sort,” since the average person prefers to downplay the psychic sufferings of fellow humans and avoid extensive contact with troubled individuals (Norcross & Guy, 1989).

The question of motivation – “Why did I (really) become a psychotherapist?” – is obviously not a simple or entirely conscious one. To be sure, altruism (“to help people”) and idealism (“for a better world”) constitute two cornerstones of the vocational choice, but it is incomplete. It begs the deeper, self-questions: Why is “helping people” of utmost concern for you? What makes it a deeply satisfying experience? Of all the helping careers – assisting the homeless, saving the environment, rendering public service, teaching the uneducated, tending to physical ills – why this career as a psychotherapist?

Even the most saintly among us is moved by a complex stew of motives, some admirable and some less so, some conscious and some less so. Psychotherapists frequently report that they come to realize the reasons they chose their discipline only well into their careers or during the course of intensive personal therapy (Holt & Luborsky, 1958).

The failure to consider the individual motives, needs, and vulnerabilities of psychotherapists renders much of the well-intended practical advice on self-care hollow and general. To paraphrase Freud, it’s akin to giving a starving person a dinner menu. One-size-fits-all treatments never accommodate many people, be it our clients or ourselves. Here, we strive to present self-care in the context of, and responsive to, the emotional vulnerabilities and resources of the individual clinician.

Running Against the Tide

We are painfully aware that our message runs counter to the zeitgeist of the industrialization of mental health care. Managed care devalues the individuality of the practitioner, preferring instead to speak of “providers delivering interventions for ICD or DSM diagnoses.” The pervasive medical model prefers manualized treatments for discrete disorders over healing relationships with unique humans. The evidence-based practice movement highlights research evidence in favor of specific treatments and downplays the evidence for the curative powers of the human clinician (and patient). Our emphasis on valuing the person of the therapist may seem a nostalgic throwback to the 1970s and 1980s.

At the same time, we detect a dawning recognition, really a reawakening, that the therapist herself is the focal process of change. “The inescapable fact of the matter is that the therapist is a person, however much as he may strive to make himself an instrument of his patient’s treatment” (Orlinsky & Howard, 1977, p. 567). This course stands firmly against the encroaching tide of the tyranny of technique and the myth of disembodied treatment.

The pursuit of technical competency has much to recommend it, but it may inadvertently subordinate the value of the personal formation and maturation of the psychologist (Norcross, 2005b). The ongoing march toward evidence-based practices tends to neglect the human dimensions of the practitioner, patient, and psychotherapy (Norcross et al., 2017). It has created an environment where, as Thoreau complains in Walden (1854, p. 25), “men have become the tools of their tools.” Movements that address only, or primarily, the techniques of psychotherapy quickly become arid, disembodied, and technical enterprises.

Lest we be misunderstood on this point, let us reveal our bias, a bias rooted in years of conducting psychotherapy and research. Effective practice in mental health must embrace the treatment method, the individual therapist, the therapy relationship, the patient, and their optimal combinations (Norcross & Lambert, 2005). We value the power of the individual therapist, but not only that. As integrative therapists, we avoid the ubiquitous pull toward dichotomous and polarizing characterizations of the evidence. The evidence tells us that successful psychotherapy is a product of many components, all of which revolve around, and depend upon, the individual psychotherapist. That’s good science and good relationships.

Research on Psychotherapist Self-Care

We have been researching the self-care and self-change of mental health professionals for the past 35 years. These studies have occupied sizable portions of our professional careers and, not coincidentally, our personal lives. We and our colleagues have conducted numerous studies to identify what distinguishes the self-change of mental health professionals from that of educated laypersons, to survey practitioners about what they use and don’t use to soothe themselves, to discern what change principles are particularly effective for therapist self-care, and to interview seasoned psychotherapists about their personal struggles and salvations. We have taken the Socratic dicta of “know thyself” and “heal thyself” to heart – and to the lab. The resultant compilation of self-care strategies is clinician-recommended, research-informed, and practitioner-tested.

Some of our earliest research, including one of our doctoral dissertations (Norcross & Prochaska, 1986a, 1986b), was premised, mostly unconsciously, on the fantasy that psychotherapists’ clinical skills would inoculate us from the inevitable stressors of living. But all of the research results have regrettably disabused us of this fantasy. Psychotherapists experience the same frequency of life disruptions as educationally and economically comparable laypersons.

We also furtively hoped that our research would compellingly demonstrate that mental health professionals would prove better self-changers than mere mortals. But here, too, we were ruefully disappointed: This is simply not the case. In truth, we psychotherapists cope just a tad more effectively with life disruptions than laypersons with similar education, which comes as an insult to our narcissism, no doubt!

A therapist-patient of ours employed at a health maintenance organization (HMO) was treating 33 patients a week at the HMO, seeing patients three nights a week in private practice, and teaching a course on another night. She then complained of feeling exhausted and overwhelmed. Duh! Her complaints followed a psychotherapy session in which another of our patients, a very hard-working teacher, stayed up past midnight creating her own Christmas bows and then complaining of exhaustion. We are not so different from our patients – we are all more human than otherwise.

A question that persistently arises and that many of you may be silently asking is, “But what about our theoretical orientations? Won’t our preferred systems of psychotherapy affect how we care for ourselves?” We have conducted multiple studies on this topic over the past four decades (see Norcross & Aboyoun, 1994, for a review). The results will probably surprise you, as they certainly did us.

In treating patients, psychotherapists use change principles in accordance with their theoretical orientation. Cognitive-behavioral therapists, for example, report using counterconditioning, contingency management, and stimulus control significantly more than colleagues of integrative, psychodynamic, and humanistic persuasions. On the other hand, psychodynamic therapists rely more on the therapy relationship and catharsis than do their behavioral colleagues. That the treatment of clients varies predictably with orientation is not surprising and, in fact, is quite expected.

The question then arose: Are psychotherapists equally influenced by theories in treating themselves, in their own self-care? Apparently not. We have been unable to discern any significant orientation differences in psychotherapists’ self-care. This pattern of results has now been replicated in five separate studies involving different disorders and health professions. Indeed, we have been unable to discern even a few statistically significant differences expected by chance alone. In toto, these composite findings strongly argue for a considerable similarity among psychotherapists in their own self-care, independent of their theories.

We offer three interpretations for this pattern of findings (Norcross et al, 1991). The first interpretation comes from attribution research. In their role as healers, therapists rely heavily on theories for facilitating change in others. In their role as self-changers, therapists are not as influenced by theoretical prescriptions.

A second and cynical interpretation holds that mental health professionals do not avail themselves of what they offer their patients. Theoretical orientations may be for treatment-facilitated change of clients, not for self-initiated change of themselves. Negatively stated, one may not necessarily have to “practice what one preaches.” As George Kelly (1955) noted many years ago, psychotherapists do not apply their theories reflexively. That is, they do not apply the same theories to their own behavior as psychotherapists that they use in understanding and treating patients.

The third and more positive explanation is that psychotherapists become more pragmatic, eclectic, and “secular” when they confront their own distress. This view is reminiscent of early psychotherapy process research that suggested experienced psychotherapists behave and think quite similarly (e.g., Fiedler, 1950a, 1950b) and also reminiscent of a “therapeutic underground” (Wachtel, 1977), an unofficial consensus of what experienced clinicians believe to be true. Psychotherapists may well value clinical strategies that are quite different from what they offer their clients or from what they consider to be within their professional competence. On a personal level, clinicians may be taking psychotherapy integration to heart.

George Stricker (1995), a friend and a prominent psychodynamicist, has written movingly about just such a personal integration in self-care. George and several fellow psychotherapists rented a small, puddle-jumping airplane in South America for an intimate view of the spectacular Iguazu waterfalls. As George looked over the falls to appreciate the beauty that led them there, he began experiencing panic symptoms. He realized that his training and proficiency in psychodynamic therapy were not particularly useful for self-management of acute panic. Ever the pragmatic integrationist, George immediately became a cognitive-behavioral therapist with the assistance of his colleagues and successfully ameliorated his anxiety. He still employs some of the cognitive-behavioral methods he was taught, when faced with similar situations. Not a cure, to be sure, but an effective way of dealing with situational anxieties.

Also consistent with this pragmatic and integrative explanation is the repeated finding that, as suggested above, many psychotherapists choose a type of personal therapy different from what they practice themselves (see Norcross & Grunebaum, 2005). The majority of behavior therapists, in particular, choose nonbehavioral personal therapy. Practitioners, it appears, have learned that rival orientations are complimentary, not contradictory, when it comes to their own health.

Our decades of research on self-care also leads us to emphasize self-care principles or strategies, as opposed to techniques. One of the lessons from our research is that effective psychotherapist self-care is characterized by a complex, differential pattern of strategies. These strategies or principles represent an intermediate level of abstraction between concrete techniques and global theory. There are literally thousands of self-care techniques (e.g., meditation, assertion, dream analysis, vacations), and, Lord knows, we cannot agree on a single theory (e.g., psychoanalytic, cognitive, systemic, narrative). However, research increasingly reveals that we can agree on broad principles. Given the diversity of individual preferences and available resources, we recommend broad strategies as opposed to specific techniques.

If a colleague is plagued by occupational anxieties, then the research suggests that the strategies of healthy escapes and helping relationships may well prove effective. Once the strategies are identified, then the individual practitioner can discover for herself the available and preferred techniques for implementing these strategies – for instance, massage, exercise, and meditation for healthy alternatives and peer support groups or clinical supervision for helping relationships. The focus should be squarely placed on broad strategies, which you then adapt to your own situation and preferences (Norcross, 2000).

Our research has additionally shown appreciable outcome differences among various psychotherapist self-care strategies, but the effect of any single strategy is rather modest. The different change strategies that people bring to bear on their distress do make a difference. The self-care strategies recommended in this course are demonstrably more effective than the passive strategies of, say, wishful thinking, self-blame, and substance abuse (Norcross & Aboyoun, 1994).

At the same time, there is no single self-care strategy so outstandingly effective that its possession alone would ensure an ability to conquer distress. These findings suggest to us, as they have to others, that possessing a particular skill in one’s arsenal is less important than having a variety of self-care strategies. Seasoned practitioners have extended valuable lessons from their clinical work to their personal lives: Avoid concentration on a single theory and promote cognitive and experiential growth on a broad front.

A recent meta-analysis of 17 studies on the efficacy of self-care among graduate students (Colman et al., 2016) supports the point. Many self-care strategies were associated with reductions in student distress and increases in their self-compassion and personal accomplishments. But there were not significant outcome differences due to the particular self-care strategy. Nor did student characteristics (sex, age, and ethnicity) make much of an outcome difference; that is, self-care is for all of us.

The overarching moral to be derived from the research is that psychotherapists should avail themselves of multiple self-care strategies unencumbered by theoretical dictates. Take psychotherapy integration to heart; that is, embrace multiple strategies associated with diverse theoretical traditions. Be comprehensive, flexible, and secular in replenishing yourself. Thus, the self-care strategies compiled in this series of courses are theoretically neutral and blend psychotherapists’ in-the-trenches recommendations with the research findings.

Self-Care as Ethical Imperative

For those not convinced or only partially convinced by the scientific evidence on the person of the psychotherapist, we now turn to self-care’s ethical imperative. Every ethical code of mental health professionals includes a provision or two about the need for self-care.

The American Psychological Association’s Ethical Principles and Code of Conduct (2010), for example, directs psychologists to maintain an awareness “of the possible effect of their own physical and mental health on their ability to help those with whom they work.” One section (2.06) of the code instructs psychologists, when they become aware of personal problems that may interfere with performing work-related duties adequately, to “take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties.”

Similarly, the National Association of Social Work Code of Ethics (2008) advises practitioners to monitor their performance, warns against practicing while impaired, and recommends “remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others.”

The American Counseling Association’s (2014) Code of Ethics, for another example, goes further in proactively instructing counselors to “engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities.” No wonder that multiple organizations have joined the National Academy of Practice (2016) to launch an Action Collaborative on clinician well-being and resilience.

Without attending to our own care, we will not be able to help others and prevent harm to them. Psychotherapist self-care is a critical prerequisite for patient care. In other words, self-care is not only a personal matter but also an ethical necessity, a moral imperative (Barnett et al., 2006; Wise et al., 2012). Not an indulgence, not an option, but a professional responsibility. We gently urge you to challenge the morality of self-sacrifice at all costs and to embrace the indispensability of self-care.

Ethically speaking, you care best for your clients when you take sufficient care of yourself. The message is that simple yet that profound and demanding.

The Paradoxes of Self-Care

Suppose you were to come upon a man in the woods working feverishly to saw down a tree. “What are you doing?” you ask. “Can’t you see?” comes the impatient reply. “I’m sawing down this tree.” You exclaim, “You look exhausted! How long have you been at it?” The man replies, “Over five hours, and I’m beat! This is hard work.” You inquire, “Well, why don’t you take a break for a few minutes and sharpen that saw? I’m sure it would go a lot faster.” The man emphatically replies, “I don’t have time to sharpen the saw. I’m too busy sawing!”

That is the first paradox of self-care: no time to sharpen the saw! The story, incidentally, comes from Stephen Covey’s (1989, p. 287) The 7 Habits of Highly Effective People. It is sooo easy to see and diagnose it in other people; it is sooo hard to get off the treadmill ourselves.

The existential-humanistic therapists Sapienza and Bugental (2000, p. 459) put the self-care paradox bluntly:

“Many of us have never really learned how to take the time to care and to nourish ourselves, having been trained to believe that this would be selfish. … Nor have most psychologists taken the time to develop compassion for themselves, and compassion for their wounds.”

Not that psychotherapists are opposed to self-care; far from it. Instead, we are busy, multitasking professionals dedicated to helping others but who frequently cannot find the time to help ourselves. Clients, families, paperwork, colleagues, students, and friends seem to always assume priority. The ideal balance of caring for others and for ourselves tends to favor the former. At the risk of redundancy, we believe it begins with prioritizing the value of yourself as a person/psychotherapist.

The point segues into another paradox of psychotherapist self-care: not availing ourselves of what we provide or recommend to clients. We often feel hypocritical or duplicitous – suggesting to others that they work less, exercise more, renew themselves, and so forth – while we do not take our own advice. How often do we sit with patients, encouraging them to “relax and take a vacation,” while calculating in our own case our lost therapy revenue and airfare and concluding that we can’t afford to take the time away from the office right now (Penzer, 1984)?

A representative example from one of our workshop participants is instructive:

“I had the ergonomic person here yesterday for an analysis in my office, thanks to back pain that signaled something negative to me. When I had to answer her questions about my amount of work, vacation, and so on, it was embarrassing! How could I possibly with a good conscience give a talk on stress management when I behave as I do?”

On a positive note, the person optimistically concluded that “I’m assuming the universe is sending me needed messages and that your reminder e-mail about self-care is yet another.”

A recurrent theme presented here is the acknowledgment that it is easier to be wise and mature for others than for ourselves. If you are still feeling a little hypocritical, sheepish, or guilty about not practicing what you preach, then join us and the crowd. We are far more adept at recommending self-care to others than practicing it ourselves, as our families and friends will readily attest. Until quite lately in our own lives, self-care was regrettably more of a research proficiency than a personal accomplishment. We are in no position to moralize.

In fact, we take seriously an early lesson of folks traveling to Esalen, the human potential center in California. Although the trainers at Esalen were teaching people how to relate to themselves and other people in optimal ways, they themselves had serious difficulties in their own lives and relationships. This led Richard Price to popularize what he called Esalen’s Law: We always teach others what we most need to learn ourselves. A corollary is that each of us is our own worst student. (Thanks to Ken Pope for reminding us of the law’s origins.)

Psychotherapists frequently comment on the cruel irony of giving to clients precisely what they deprive their families of. One therapist (Penzer, 1984, p. 54) notes the dissonance inherent in “spending several hours a day playing Uno, Checkers, and War in the name of play therapy and coming home in the evening and casting my children’s requests aside in the name of fatigue.” Another colleague was conducting psychotherapy with a harried middle-age father one evening and focusing on the father’s need to spend more time with his son and daughter. Alas, the therapist was seeing patients four evenings a week and ignoring his own young children!

Many therapists will candidly admit to giving more time, energy, and devotion to their practices than to their spouses, children, or themselves (Penzer, 1984). Clearly, the lesson is one of “Physician, take thine own medicine.”

Just as being a lawyer does not necessarily make one more honest and being a physician does not necessarily make one healthier (Goldberg, 1992), so too being a psychotherapist does not make one automatically more proficient at self-care. In fact, it is frequently the converse in a profession which people enter “to help others.”

Begin with Self-Awareness and Self-Monitoring

Quantitative studies and interview surveys alike confirm the conventional wisdom on the centrality of self-monitoring our own distress and, concomitantly, our own self-care.

In one illustrative study, both program directors and professional psychologists identified “self-awareness/self-monitoring” as the top-ranked contributor to their optimal functioning (Schwebel & Coster, 1998). In a survey of 595 psychotherapists, “maintain self-awareness/self-monitoring” emerged as the second highest rated career-sustaining behavior for the entire sample, right behind “maintain sense of humor” (Rupert & Kent, 2007). In a study of master therapists, self-awareness was deeply embedded in, and routinely prized as a prerequisite for, professional conduct (Skovholt & Jennings, 2004).

Becoming aware, as we usefully remind our patients, is the key first step. In a monumental multinational study of psychotherapist development over the lifespan (Orlinsky & Ronnestad, 2005, p. 200), the authors pointedly conclude: “As a final recommendation, then, we restate how important it is that practitioners of all professions and theoretical orientations consistently monitor and carefully attend to their sense of current professional development and their level of satisfaction with therapeutic work” (italics in original).

Assess your own self-care as you might a student’s or a patient’s self-care. Be prepared to be shocked by the results. You spend most of your day in intimate contact with distressed patients, anxious parents, and insensitive administrators? You work how many hours per week?! Your last non-convention vacation was when?! You never get lunch at the office?! And then you take work home with you and receive calls at night?!

Structured questionnaires can serve as convenient, empirically grounded measures in facilitating systematic self-reflection (Orlinsky & Ronnestad, 2005). Practitioners might use questionnaires to monitor their own work morale and establish benchmarks for detecting signs of stagnation or decline. Student therapists might use them privately to monitor their own clinical functioning and development and share the results with supervisors. Supervisors, in turn, might use them in parallel fashion to track supervisee’s distress, self-care, and development. (See Appendix E in Orlinsky & Ronnestad, 2005, for sample questionnaires, scoring keys, and norms for psychotherapists; complete one of the dozen or so resiliency, compassion fatigue, or self-care instruments; or consider one of the burnout instruments, such as the Burnout Measure or the Maslach Burnout Inventory.)

Research suggests that, unfortunately, clinicians are not necessarily the best reporters of their own abilities and behaviors (Lambert, 2010; Waltman et al., 2016). We all need to supplement our self-monitoring with objective measures, peer consultation, and independent verification. Self-care begins with our own awareness, but cannot end there.

Many practitioners find it useful to track their self-care through writing, journaling, or logging (e.g., Baker, 2003; Williams-Nickelson, 2006). Some prefer structured self-monitoring on a specific behavior, such as food diaries, mood and self-talk logs, or exercise calendars. Others prefer a narrative journal of feelings and experiences. Meta-analyses on the effects of expressive writing find (small) positive effects on physical and psychological outcomes (Frattaroli, 2006; Frisina et al., 2004). In any case, a written chronicle improves adherence to a self-care regimen (DiMatteo, 2006) – of course, so long as maintaining the journal or log does not itself become yet another onerous responsibility or compulsive pursuit.

Gerald (Jerry) Corey, author of several influential textbooks on counseling, exemplifies the self-monitoring of work and play. For years, Jerry has recorded the time devoted to work and to exercise (walking and biking). Since the year 2010, he has averaged 39 hours of work weekly and an impressive 13.6 hours of exercise weekly. Jerry testifies that logging his work and exercise time keeps him more honest, balanced, and motivated.

Several of our workshop participants have taken to posting publicly their self-care plans to promote maintenance and to share their commitment with peers and patients alike. One wrote: “I have my self-care goals written out on my name tag from the workshop and tacked to my bulletin board so I can see them often. For a guilt-ridden type like me, once we commit to something in public it sticks.” Another concurred, saying, “It has become more acceptable for me to discuss and overtly integrate my self-care strategies with colleagues.” Your self-care can prove a contagion, spreading beyond colleagues to clients.

Self-awareness can be augmented by contracting for some honest feedback from loved ones about our workweek. Self-awareness does not imply that we go it alone, only that we must become aware of and own our behavior. For some of us, self-monitoring entails attending (nondefensively, if possible) to interpersonal feedback from significant others about our functioning.

In our case, we attend to our spouses’ observations that we are looking haggard, working longer hours, or traveling too often, to supplement our own monitoring. In the early years, our defenses were immediately activated, and we quickly rationalized with such feeble protests as “Well, I have a responsible position;” “But it’s not as bad as Jim’s schedule;” and the ever handy “Next week will be easier.”

Awareness alone, however, is not sufficient. Self-care readily becomes one of those “healthy oughts,” like flossing teeth and getting sleep, which gets discussed and then discarded. Here’s how one workshop participant characterized his history of neglecting self-care:

“Somehow my wonderful plans and desires based on my emotions did not materialize. I yet once more realize the various steps in actual life transformation. Awareness is not enough, and understanding is only the beginning of the essential first step.”

In several of our studies devoted to discovering the successful self-change strategies of psychotherapists, self-liberation – a fancy name for choosing and self-realization – consistently emerged as an effective strategy. This strategy entails the choice of changing and the ensuing responsibility. It is the acknowledgment, the commitment, and the burden of replenishing yourself, professionally and personally.

In the prophetic words of a participant in one of our self-care workshops:

“Your presentation was a necessary reminder to me that I cannot just advocate attention to self-care for my staff or assume that it will stay in my consciousness without some intention. I need to apply it, more consciously and intentionally, to myself. It caused me to reconsider things I was and was not doing to engage in self-care.”

That, in a nutshell, is precisely our intention.

Building on Your Self-Care Strengths

Part of our intention is to identify what you currently do well in self-care. An unfortunate side effect of writing on the wondrous variety of self-care is that readers commonly conclude that they fall short of the self-care ideal and, in fact, are not replenishing at all. Nonsense! Let’s acknowledge what you are already doing and build on those strengths.

Take a mindful moment to document existing self-care activities you desire to continue. Construct a mental list or jot them down; the research demonstrates that writing a list generally proves more effective than thinking about them, so we ask our workshop participants to take pen to paper. Perhaps share them with peers or friends to enhance compliance. Sure, you might want to do them more regularly, but start your well-being from a position of strength and celebration about what’s already working.

Some supervisors take the idea a step further: They ask their staff members to write themselves a self-care letter, seal it in an envelope, and then return it to the author 3-6 months later. Writing the letter and subsequently receiving it ideally serve as momentum and focus on self-renewal (Magaletta & Perskaudas, 2016).

Making Self-Care a Priority

To reach the action stage of sustained behavior change (Prochaska et al., 1995), awareness and self-monitoring must beget a proactive choice. Good intentions must concretely translate into healthy behaviors. “I find that it really works to write in my exercise time on my calendar each day and make that a really important time,” one colleague told us. In other words, we must make self-care a priority.

It begins with reminding busy practitioners of the personal and professional need to tend to their own psychological health. Call it valuing, prizing, prioritizing, or another action verb, but find a way of building it into the mainstream of your life. Self-care is not a narcissistic luxury to be fulfilled as time permits; it is a human requisite, a clinical necessity, and an ethical imperative.

If not us, then who will value our self-care? Certainly not our clients, who neurotically would bleed us to death if permitted. Certainly not insurance carriers, who greedily demand more of us while doling out less reimbursement and less autonomy. Hopefully our loved ones, but they understandably have their own needs and agendas, which only partially match ours. No, if anyone is to advocate for and prioritize our replenishment, it must be us.

The famous Talmudic injunction "If I am not for myself, who will be for me?” seems particularly difficult to implement for women socialized to place nurturing others above all else. And women, let us emphasize, now comprise the majority of new graduates of all mental health professions (psychology, psychiatry, social work, counseling, marital and family therapy, mental health nursing). Practicing self-care is often mistranslated as selfishness and into abandoning others. We join Carol Gilligan (1982) and other feminists in challenging such women to question the morality of self-abnegation and “to consider it moral to not only care for others but for themselves” (p. 149).

Many clinical colleagues and more than a few of our master therapists post mottos, photographs, or plaques to remind them of the self-care foundation. A few of our favorites read:

• You cannot drink from an empty cup.
• Put on your own oxygen mask before helping those around you.
• Limited self-care means limited patient care.
• You can’t help others if you don’t help yourself first.
• Self-care is a divine responsibility.

Self-awareness and self-monitoring should beget self-empathy and self-compassion: the capacity to notice, value, and respond to our own needs as generously as we attend to the needs of others (Murphy & Dillon, 2002). Many practitioners blame themselves for feeling drained and then, to complicate the drain, berate themselves for feeling that way. Please develop self-empathy, taking the time and space for yourself without feeling selfish, guilty, or needy.

Consider the daily life of the “successful” busy psychotherapist in independent practice. Up early and tending to family matters. Off in a rush to the office to “catch up,” return telephone calls, and complete insurance forms. Confronting an avalanche of suffering patients and juggling them with the emergencies. Squeezing in a part-time teaching, supervision, or consultation commitment. Working several evenings, perhaps even a weekend day. Taking calls at night, completing paperwork at home. The line between work and non-work has practically disappeared.

Or consider the committed “successful” clinician working at a community mental health center. One of our workshop participants characterized her agency as one “that would chew me up and spit me out, then ask that I reassemble myself so they could have dessert. It is impossible to do what I am asked to do. I am salaried and work far more than 40 hours a week (from 45 to 50 hours).”

Or the pastoral counselor who wrote us recently about his new position at a hospital as “a chaplain, and it is mega stressful. I am on call for 104 hours per week. There are people dying of cancer and other diseases every day. This week I have been working with a young couple when doctors turned the life-support machine off on their little baby.”

All are working overscheduled lives. Skimping on breakfast, probably skipping lunch, existing on snack foods during the day on the run. Running nearly on empty, subclinically exhausted. Little time for self or loved ones. In a success-driven culture hostile to rest and self-care, many psychotherapists have lost the balance, priorities, and mission they once treasured. Quis custodiet ipsos custodies? (Who will guard the guards?)

For those still subscribing to the myth of therapist invulnerability, longitudinal research documents the obvious. Excessive work demands of mental health professionals predict worse work-family conflict. Specifically, more hours worked and greater emotional exhaustion lead to poorer family functioning in the future (Rupert et al., 2013).

Nor can we hide our humanness from patients. Several studies have demonstrated that our clients are sensitive to the quality of the clinician’s life outside of treatment (Briggs & Munley, 2008). The higher the therapist’s personal burdens, the worse the therapeutic alliance; the higher the therapist’s personal satisfactions, the better the treatment alliance (Nissen-Lie et al., 2013). Our burdens – and our satisfactions – are communicated to clients and obviously impact therapeutic success.

A simple and surprisingly effective method for prioritizing self-care is to make the calendar work for you. Schedule the activities that matter most to you on your calendar (Weiss, 2004). One of our master therapists told us that “I write down the consequential before the mundane in my schedule book. My lunches with friends, exercise times, and family events are there every month.” Of course, putting something into your schedule typically means taking something out of your schedule. That active choice entails both pain and freedom.

Another master therapist described this approach to us: “In training new staff, one of the top 10 points I orient them on is to never schedule anything for me between 3 p.m. and 6 p.m. on Tuesday. That is MY time to refresh and reenergize. It is when I visit my chiropractor, get a massage, and sit in the sauna.”

Valuing You

Celebrate the person of the therapist in general, and you in particular, friend. Where others fear to tread and run away, you plunge forward into the darkness in the service of others. We ask that all mental health professionals internalize portions of Walt Whitman’s Song of Myself (1892): “I celebrate myself, and sing myself.” Later: “I am large, I contain multitudes.” And, we ardently hope: “I dote on myself, there is that lot of me and all so luscious.” Without resorting to grandiosity, therapists perform godly work.

The goal is not simply to survive, but to thrive – in practice and as a psychotherapist (Pope & Vasquez, 2005). Not only to keep your nose above the waterline, but to swim naturally and joyfully.

Our goal leads us, curiously enough, to barely mention how to “avoid burnout.” That would be equivalent to discussing how to avoid catching a cold, how to avoid a bad marriage, or how to avoid an automobile accident. Trying to avoid burnout, while noble in intent, is avoidant as a strategy, reflective of a psychopathology orientation, and negative in purpose. As one of our workshop participants wrote, “It was important to hear you refocus self-care away from the negative of avoiding burnout toward actually living well.” Exactly so.

Our message is that it is far more productive to promote self-care. Sure, we can temporarily alleviate the distress of clinical work; but, more optimistically and proactively, we can value and grow the person of the psychotherapist.

Self-Care Checklist

• Adhere to the ethical imperative of engaging in self-care to maintain and promote your emotional, physical, mental, and spiritual well-being to best meet your professional responsibilities.

• Ask your patients, if you have not done so recently, what has been most helpful in their psychotherapy. Take to heart their frequent compliments about your presence, affirmation, and support.

• Resist the pressures of managed care to define yourself as a nameless and disembodied “provider;” maintain your individual identity as a distinctive practitioner of psychological healing.

• Internalize the relational crux of the work. Yes, we conduct treatments to eradicate DSM disorders, but we also offer relationships that heal and strengthen people.

• Assess your deep motives for becoming a psychotherapist beyond the altruism of “to help people” and the idealism of “to improve the world.” How are the selfism motives facilitating or hindering your effective self-care?

• Take a mindful moment to identify existing self-care activities you desire to continue; start from a position of strength and celebration about what’s good.

• Prioritize your self-care: put specific times in your schedule to sharpen the saw.

• Develop self-empathy and self-compassion: the capacity to notice, value, and respond to your own needs as generously as you attend to the needs of clients.

• Practice what you preach to your clients about nourishing the self: avail yourself (when applicable) of what you provide or recommend to clients with similar needs.

• Embrace an integrative mix of effective self-care strategies (as opposed to relying on a single theoretical orientation).

• Avoid concentrating on a single self-care technique, and promote cognitive and experiential growth on a broad front. Do you rely on only one or two self-care methods?

• Assess your own self-care as you might a student’s or a patient’s self-care – on a weekly or monthly basis.

• Track your renewal by maintaining a journal, calendar, or behavioral log of activity.

• Complete structured questionnaires on resiliency, burnout, and self-care periodically to facilitate your self-awareness.

• Consider publicly posting your action plan to bolster your compliance and to model self-care to peers and patients.

• Contract for some honest feedback from significant others about your workweek, functioning, and self-care. Let others supplement and enhance your self-monitoring.

• Track the emotional residue you’re taking home from your professional work.

• Put your consequential self-care activities in your schedule/calendar first thing every month. Literally schedule your self-care.

• Celebrate mental health professionals in general and you in particular!

• Alleviate the distress of conducting psychotherapy, to be sure, but also value and grow the person of the psychotherapist.

Setting Ethical Boundaries

“No.” is a complete sentence.

– Anne Lamott

“How can I cut my hours down to 40 and walk away feeling justified? This really nails the dilemma for most of us. How to hold the line, shorten sessions, just say no, and so forth. In a nutshell, I think it requires a profound cognitive-emotional shift – helpers have needs too. Can I say ‘no,’ ‘enough,’ ‘good enough for now’ and still feel professional, effective, and ethical?”

Thus wrote one of our workshop members in reflecting on the fundamental conflict in her self-care. How do we balance the needs of patients with the needs of ourselves? How do we set consistent boundaries that enable us to connect with patients and, at the same time, separate from them (Linden, 2008)? In short, how do we navigate between the twin perils of emotional fusion/enmeshment on the one side and sterile detachment on the other?

The process of clarifying and balancing relationships poses complex challenges and can become a source of distress among practitioners, particularly when confusion exists regarding roles and expectations. Psychotherapists experiencing difficulty establishing clear, reasonable boundaries will almost certainly have trouble leaving it at the office.

In a general sense, boundary implies a marking point between two domains. In the psychotherapeutic sense, boundary means a line or limit that should not be crossed or violated. For psychotherapists, boundary demarcates separation in at least three senses: between yourself/therapist and others/clients; between your professional life and your personal life; and between effective or ethical practices and the ineffective or unethical.

Here, we address the self-care concerning the first two meanings. In all senses, the primary function of boundaries is to provide a safe and predictable environment in which the patient can work and the therapist can render effective care. The overarching goal is to maintain clear yet flexible boundaries, which leads to reduced stress, less emotional fusion, and greater satisfaction.

We are in the mainstream in suggesting that therapists manage daily boundaries for the benefit of their patients and for themselves. Being regular, predictable, and punctual does not replicate the chaotic life history that many patients bring to treatment. Some psychotherapists, especially those of psychoanalytic origin, prefer the term therapeutic frame. The holding environment and the comforting structure of office policies reassure patients. Boundaries serve to maintain safety and integrity in the psychotherapeutic process (Epstein, 1994).

At the same time, we are mindful that consistently managing boundaries can deteriorate into rigid, even punitive, behavior that causes ruptures and threatens the therapeutic alliance. While we advocate for boundaries, we also advocate for reasonable flexibility. The results of research indicate that most patients make relatively few requests about extending boundaries and that psychotherapists accommodate those requests most of the time (Johnston & Farber, 1996). Such practice suggests a spirit of good will, flexibility, and collaboration. We allow flexibility within limits – the bend-but-don’t-break rule. Accordingly, in the following pages, we hope that our insistence on setting and maintaining boundaries is interpreted as consistent and predictable, yet flexible.

Not surprisingly, research bears out the self-care value of clear yet flexible boundaries. Psycho-therapists who maintain clear boundaries feel less stressed by patient’s psychopathology and suicidal threats. By contrast, therapists with greater fusion tendencies experience more stress from patients’ pathology and suicidality and report more professional doubt about maintaining the therapeutic relationship (Hellman et al., 1987). Again, we encounter the inescapable interaction of the therapist’s personality and the hazards of the work.

Setting boundaries consistently emerges in the research as one of the most frequently used and one of the most highly effective self-care principles. In one study of boundary behaviors used to prevent distress and impairment (Sherman & Thelen, 1998), 72% of psychotherapists scheduled breaks during the day, 59% kept their caseload at a specific level, and 56% refused certain types of clients. These are impressive numbers, but in an ideal future we hope these numbers would top 90%!

In this course, we advance the self-care imperative of setting boundaries both at the office and away from the office. A common thread among passionately committed (Dlugos & Friedlander, 2001) and master (Harrison & Westwood, 2009; Skovholt & Jennings, 2004) psychotherapists is their insistence on creating boundaries between their professional and nonprofessional lives. The master clinicians interviewed for this course are unanimous in declaring that boundaries must be established to ensure the well-being and relationships of the psychotherapist. In fact, establishing clear boundaries was the single most frequent self-care strategy among our 30-plus master clinicians.

Setting Boundaries at the Office

Boundaries at the office encompass an intersecting network of role definitions: what is in bounds and what is out of bounds for the professional, the patient, their therapy relationship, colleagues, family, and friends. We consider each in turn with an eye toward self-care.

Defining the Role of the Psychotherapist

It is paramount that the psychotherapist understand her role and its limits. She must recognize personal strengths and limitations and establish clearly defined boundaries (Gregory & Gilbert, 1992; Pope, 1991). This is done in a number of ways, but begins with and requires self-awareness.

The psychotherapist who understands her role, as defined by theoretical orientation and personal style, will have an easier time clearly communicating this persona and professional service to the client. This process will help shape expectations and reduce misunderstanding and disappointment. This may be as basic as deciding how many total hours the psychotherapist will work each week, which nights (if any) she will be available for appointments, and how many breaks will be necessary throughout the day to ensure quality care. How available will the clinician be for telephone contacts, crisis sessions, and multiple appointments per week? All of these decisions require an awareness of the relation between the psychotherapist’s professional practice and personal life.

A master therapist put it this way:

“I make it clear that I keep clinical work in my office during my workday and try not to bring it home with me. My family time is family time, leisure time is leisure time, and work time is work time. I set those boundaries in my own mind to try to keep clinical work in the office. I have to make a decision to not worry about a client who is telling me he or she is doing something that is putting them at risk.”

A licensed counselor wrote three months after a self-care workshop that “I now find ways to achieve balance and accept tasks that are left unfinished. I am surprised that I have been able to care ‘less,’ however, it has not reduced the quality or the results of my work. It has helped me change my focus on what is more important in life, which is not unrealistic deadlines at work!”

Consider the number of hours a practitioner is willing to work each week. The goal of some therapists is to do as much psychotherapy as possible per week – that is, until they begin to “drift away” during sessions, offer mechanical responses, or are unable to physically tolerate another session. We suggest that the goal should be doing as much therapy as you can do well.

Everyone has a different limit. Albert Ellis, one of the fathers of cognitive-behavioral therapy (CBT), famously did 60 hours a week, while others max out at about 30 contact hours. The goal is not more psychotherapy but better psychotherapy. Determining your own workload should be based on observing and honoring your feelings. If you find yourself becoming irritable, distracted, and exhausted during many workdays, then please heed those feelings and take corrective remedies.

Most of us are socialized to work to capacity (100%) or above capacity (110%). We recommend working under capacity (90%) so that emergencies, family demands, and self-care can be accommodated and, indeed, built into the weekly schedule.

Those of us who measure our “success” by the fullness of our appointment book and the number of sessions scheduled per day can come to regard unanticipated or unscheduled free time as a blemish to be hidden as quickly as it appears (Penzer, 1984). How easy it is to skip lunch in order to see another patient!

Overwork is a curse of our time and simultaneously a badge of honor (Grosch & Olsen, 1994). Listen to a busy practitioner “complain” about her full schedule and overwork: it is a mix of grumbling and bragging expressed in the neologism of humblebrag). What an important, esteemed healer I am! Here is where the masked narcissism of many psychotherapists reveals itself.

This is a paradox of self-care: Many of us embark on helping careers out of a genuine concern for others, but also with a need to be appreciated by them (Grosch & Olsen, 1994). We must realistically assess and continually monitor our need for appreciation, the deep desire to be liked and admired. Such motives may easily drive us to overwork.

A related paradox: Being overly concerned about clients burns out psychotherapists, but also motivates them! A meta-analysis of 17 studies concluded that overinvolvement with patients was the biggest predictor of symptoms of burnout. But that same overinvolvement predicted high levels of personal and professional accomplishment. We work harder and longer to provide the best care, but that accomplishment comes at the risk of our own mental health (Lee et al., 2011).

Consider, too, the nature of session fees. In the ratio of length of professional training to average income, mental health professionals occupy the bottom rungs. Conducting psychotherapy as a licensed professional requires at least a master’s degree. How many MAs and MSWs out-earn MBAs? Or PhDs out-earn MDs? Psychologists, in particular, are at real risk of becoming the health care professionals with the longest training (average of six years post-baccalaureate) but the lowest incomes. We may become a masochistic profession in which we take care of the legitimate needs of others but not of ourselves.

The psychotherapy literature has been hesitant to talk about money (Rappoport, 1983). The profession has come out of the dark more recently, given the ravages of managed care, but money remains a deeply ambivalent taboo to most mental health professionals. We suffer from moral uneasiness about profiting from the emotional pain of others. Can you “do good” while doing (financially) well?

Boundaries demand livable wages and a reasonable return on the investment that is required to become a licensed practitioner. Income deserves to be addressed for the major dimension and reality element it is. None of us enters the profession solely for the money, for most of our occupational rewards are nonmonetary. However, we deserve a “good enough” income. And we deserve, on both psychological and business levels, to speak about the value of our professional time (Asay, 2014).

The research suggests that even a modicum of direct-pay clients correlates with and predicts career satisfaction among mental health practitioners. Such patients do not involve the extra paperwork, the loss of control over treatment decisions, and the ethical concerns of “approval” from faceless third-party insurance companies. Having even a quarter of one’s caseload composed of clients who pay directly provides sufficient relief, satisfaction, and autonomy (Rupert et al., 2012).

And consider how some psychotherapists deal with patients late for their scheduled appointments. We frequently encounter therapists who will see patients for their entire scheduled time (e.g., 30 or 50 minutes) even if the patient (or couple) has arrived late for the appointment. As a result, subsequent appointments are pushed back for the remainder of the day. These therapists seem to be always running late and perpetually exhausted (Boylin & Briggie, 1987). Our advice is to maintain the time boundaries. See patients for only their scheduled time and only extend appointments on rare occasions when truly warranted.

Consider as a final example of psychotherapists’ role definition the matter of availability outside of sessions. Each therapist must decide what she can realistically offer, keeping in mind how committed she is to her personal needs versus those of the client. The following disclosure by one of our master clinicians demonstrates one way of handling this conflict:

“I encourage people to contact me only in true emergencies. Sometimes we talk specifically about when it is appropriate to call me. When there are clinical issues that require their calling me, I label it clearly. I try to be prompt and clear about telephone calls that I get and return. I also try to be on time with sessions. I let [clients] know that I don’t give extra time in sessions unless there seems to be an extraordinary reason.”

Practitioners naturally differ in their policies for out-of-session contacts. On one end, some of our colleagues maintain only voicemail with a message advising their patients to go to the emergency room in a crisis. In the middle are those who maintain a cell phone or answering service but are clear that they frequently cannot be reached. On the other end are those who take calls 24/7.

We offer no self-care advice on which of these policies is optimal for your particular circumstances, but would offer four self-care caveats. First, it is a decision that should be made by you, not by your patients. Second, your decision should be clearly communicated to patients and potential patients. Third, when possible, limit your out-of-session exposure to crises by minimizing on-call circumstances, referring patients to the emergency room, and dividing calls among fellow professionals in your agency or in your office. When on your own time, surrender the cell phones at the door! And fourth, thoughtfully select patients and clinical circumstances that fit with your on-call availability. Practitioners who are not generally available and who do not have backup arrangements should not be taking on chronically suicidal patients in their practices, for one obvious example.

Exceptions are the rule in clinical practice, of course. Circumstances may occasionally demand that the clinician extend herself beyond stated limits to assist a client undergoing extraordinary difficulties. Sliding-scale fees, pro bono sessions, extra sessions, late-day appointments, and telephone contacts may be necessary from time to time. However, in such situations the therapist should remain in the position of deciding the appropriateness of the exceptions and should clearly demarcate them as exceptions.

If you are in private practice, be clear with patients about what out-of-session contact is charged or not charged. Scheduling matters are not generally billed, but panic calls in moments of high anxiety to calm the patient is a therapeutic contact and should be considered for billing (in a prorated manner involving the time taken by the contact). If you answer text messages and e-mail outside of your office hours, let your patients know the times in the evening or weekend you generally do so. Specify the types of messages you respond to during that time period, which in most cases will revolve around cancellations, rescheduling, and similar appointment coordination. In this way, you are responsive to changes in clients’ life and work schedules.

Responding immediately to patients’ texts and e-mails creates unneeded stress on yourself. When will the next one arrive? Responding as soon as they arrive also creates an unrealistic expectation of immediate responsivity in the patient’s mind and additional pressure on you to be omni-available. We have heard far too many tales from aggrieved spouses and children about dinners, conversations, and family events being interrupted by relatively unimportant patient contacts.

The length of the therapy session is not set in stone and, in fact, 50 or 60 minutes is not supported by the research evidence either. Scores of psychotherapists have gravitated to a 45-minute “hour” to allow sufficient time for scheduling, documentation, and a mindful reset between patients.

Time management constitutes the Achilles’ heels for many of us. Taking time for ourselves while clients wait poses an enormous challenge for the altruistic and idealistic practitioner. The internal talk still asks, “How rude and self-important to keep others waiting!” That’s the cognitive-emotional struggle with responsible assertion.

Repeatedly assess your needs and priorities in order to be clear with your clients as to what you offer – and do not offer – as part of the treatment contract. Establish a personal policy and a method to determine whether a particular boundary has been crossed. Boundary violations are frequently realized only after the fact; it is a recursive process of trial and error that requires vigilant self-monitoring. By understanding, monitoring, and maintaining your boundaries, you will better communicate them unambiguously and unapologetically to your clients.

Defining the Role of the Client

Few would disagree that there must be a clear set of expectations established for psychotherapy clients (Gutheil, 1989). Ethical principles governing the practice of psychotherapy require informed consent, which includes discussing the role of the client and securing mutual agreement on terms before commencing treatment.

For the psychotherapist, however, the fecal matter hits the boundary fan in trying to honor both patients’ desires and self-preservation. The decision to give 15 extra minutes to a patient means you leave 15 minutes late from the office or arrive 15 minutes late for your child’s piano recital. Research has no easy answers here, other than that achieving the right balance is an ongoing process requiring continuous self-monitoring, judicious compromises, and consistent boundaries.

Good practice demands that psychotherapists help clients verbalize their role expectations early in the treatment process and then reach an explicit consensus. Goal consensus and collaboration do contribute to effective psychotherapy (Tryon & Winograd, 2011).

At the same time, self-care demands that psychotherapists communicate and maintain their boundaries. For example, one’s fees for services always need to be defined. Is the fee to be paid in full at the time of the session? Should the fee be paid at the beginning or end of the session? Should the fees be paid once per month, and by how many days after billing? Is it allowable for the client to carry a balance in his or her account? If so, is there a limit to how much the client can owe the therapist before treatment will be discontinued? How will insurance reimbursements be handled? All these arrangements should be specified in advance of commencing services.

Similarly, policies regarding the scheduling of sessions are discussed at the outset of treatment and maintained throughout unless mutually revised. Will the sessions be weekly? What will be their length? Will they include anyone besides the client, such as might occur in couples, family, or group psychotherapy? How will late arrivals be handled? The cancellation policy must be discussed so that the client knows the expectations of the psychotherapist regarding missed sessions, rescheduling, and breaks due to illness or vacations.

Of late, clients’ expectations of their therapist’s availability between sessions have mushroomed. As noted above, are you available for occasional e-mails? Do you charge for phone calls? Will you Skype with patients if they are traveling? Policies regarding contacts between sessions must be explained, including any associated costs to the client.

Increasingly, psychotherapists are gravitating toward the use of informed consent forms that contain many of these important policies. The forms may be handed to clients to read, discuss, and then sign as a written treatment contract or, alternatively, may be used by practitioners as a template for topics to be covered during the initial sessions. (For sample forms, see trustinsurance.com/Resources/Download-Documents and kspope.com/consent/index.php.) In both methods, the form contains information regarding appointments, fees, cancellations, billings, payments, extra session contacts, crisis contacts, release of information to third parties, managed care reimbursement, HIPAA regulations, exceptions to confidentiality, and so on.

Preliminary research shows that informed consent forms yield many practical benefits to the patient – more information, more comfort, a more favorable impression of the therapist – and to the therapist – feeling more thorough in covering essential topics, feeling more protected in a legal and ethical sense (e.g., Pomerantz, 2010; Sullivan et al., 1993). Despite these findings and despite our positive experiences with them in our own practice, we are concerned that lengthy, legalistic forms may misconvey the essence of psychotherapy. This is a continuing challenge about which a clear course of action remains unclear, in our opinion.

At the conclusion of therapy, expectations for the future must be discussed. In particular, what if any contact will be permitted between the client and the therapist? Who will initiate the contact? One of our studies revealed a great deal of variation on post-termination contact (Guy et al., 1993). Although 86% of psychotherapists surveyed avoided social contact with former clients, 78% allowed the exchange of letters, 79% permitted telephone contact, and 93% encouraged future therapy sessions when needed. In nearly all of these cases, the subsequent contact was initiated by the client. For the conscientious psychotherapist, there are ways in which treatment relationships never ends. A meaningful discussion of these issues during the termination process will lessen the possibility of unrealistic expectations or patient disappointment.

Defining the Boundaries of Treatment

Health care professionals must ethically and clinically delineate the nature of psychotherapy early in the treatment process. This focus fosters the alliance, increases its effectiveness, and reduces misunderstanding regarding the boundaries that are to be a part of this intimate encounter.

One prevalent assumption of clients, particularly clients new to the process, is that the psychotherapist will fix, heal, or “treat” them. Patients overly socialized in the medical model expect to be the relatively passive recipient of services unilaterally dispensed by an expert doctor who is largely in charge and responsible for the outcome of treatment.

Such a patient perspective unfortunately fits with a conventional view of therapist distress and burnout as caused by the grueling nature of the work and the experience of failure. The emotional exhaustion and intrapsychic depletion characteristic of burnout can result from overresponsible therapists who too readily assume responsibility for their clients’ lives or feel they need to save or rescue them. This often represents a boundary (and thinking) problem: overresponsibility.

As one of our master therapists put it:

I am a mother, and I am a good Catholic. That means I am responsible for others. I have a tendency to overfunction on behalf of others. I often feel that I need to think through all of the things that might happen and all of the responses my patients might have to them in order to prepare them for making the best decision possible. That is a lot of work, and it clicks in almost automatically. I need to guard against it; I need to stop myself. I need to engage them (not me) in thinking through the possible future events in their life and the range of options they have to address them. Doing that is better for them and less stressful for me, particularly in the long run.

An alternative perspective about burnout is that we become dispirited, not because we are failures, but because our hierarchical view of therapy emphasizes our ideas and actions while according little attention to our clients’ perspectives. When we assume the one-up position of expert, then we become responsible for change.

Instead, we emphasize early in therapy our mutual responsibility for both the process and the outcome. Psychotherapy demands a highly collaborative process, beginning with our thinking and ending with behavior within session. We discuss shared responsibility for change. Yes, we are experts in some respects, but a “fellow traveler” in other respects.

One method for facilitating shared responsibility is “transparency” (White, 1997) or “cultural humility” (Hook et al., 2013), in which the therapist owns personal ideas and communicates possible frailties and empathic lapses to clients. We (e.g., the authors) might acknowledge to the patient that “our backgrounds as heterosexual white men may not allow us to fully appreciate your experiences as an African American woman. Should that occur, please let us know” (McCollum, 1998). Active collaboration sets boundaries and reinforces mutual responsibilities for the change process and treatment outcomes. Such honesty and openness to clients are also positively associated with a strong working alliance and improvement in therapy (Hook et al., 2013).

An administrator made several boundary commitments following our self-care workshop. To wit: “I will stop ‘fixing’ everything. Let other people make mistakes, and don’t engage in prevention or fixing if they do. Don’t do everything I know how to do, even though it’s not my job, just because others know I know how to do it. It’s the only way for people and institutions to learn.” Sharing responsibility with patients (and with colleagues) is a boundary fix.

The challenge is to maintain that shared responsibility and relationship demarcation. Psychotherapy must not be compromised by blending it with other possible interactions; for example, the therapist and client must not enter into other types of relationships together. They are not free to become business partners, professional colleagues, friends, or lovers. It is typically not appropriate for them to meet in other contexts that require additional roles that may conflict with those of client and psychotherapist. To work, play, study, or live together would most likely undermine the nature of the psychotherapy relationship. The clearer the boundary is in this regard, the more effective the treatment will be.

Our master clinicians were nearly unanimous in communicating often with clients about the boundaries to be respected. The following is typical:

“I had a patient who was celebrating a birthday. She wanted to invite me to the party, and she was hoping that I would go. We talked about it, and what it would mean to her if I did go. By helping her describe what it would mean, she got to issues that were important to her in the therapeutic process. It reminded her of things that she needed from her mother and father and did not get. Keeping myself in the room with the patient rather than going to a social event proved a useful therapeutic redoing. Had I gone to the party, it would have been a therapeutic disappointment. It helps me to set boundaries with patients, and it gives me more confidence in the treatment. I don’t touch patients, talk much about myself, or talk to family members of patients. I don’t socialize with patients. I have a whole constellation of boundaries that I set.”

This advice converges with the research on extra session contacts with our psychotherapy patients. For example, about 60% of psychotherapists never accept an invitation to a client’s party or social event and about a third rarely do so (Pope et al., 1987). We fall squarely between the never and rarely camp. Frequent social excursions can contaminate the therapeutic relationship, violate a nonsexual boundary, and interfere with the sanctity of a therapist’s private life. At the same time, we do flexibly make exceptions when the patient’s health and circumstances seem to require it.

In a nutshell, maintaining boundaries entails saying “no” when deemed to be in the interest of the patient’s treatment and/or in the interest of the psychotherapist’s effectiveness. Herb Freudenberger (1983), father of the term burnout, has written eloquently of the need for health practitioners to say “no.” Strive not to be perfect or to cling to the ego ideal of perfect, compulsive caregiver. It is not your job to meet everyone’s needs. Your goal is always to get people to push their own wheelchairs, even if they are never able to walk again (Berkowitz, 1987).

Saying “no” will necessarily come in many guises. These include:

• “No” to patient requests for routine exceptions to your policies regarding no-shows, cancellations, and unpaid bills.
• “No” to patients making emergency calls and sending e-mails that are not emergencies.
• “No” to patients trying to extend the length of sessions on a regular basis. (Many colleagues use a soothing chime to demarcate when the session time ends.)
• “No” to potential patients who seek treatment for disorders or services (e.g., psychotic, forensic evaluations) that you are unable or unwilling to provide.
• “No” to accepting high-risk or suicidal patients into your practice when you are already stretched thin.
• “No” to an agency’s excessive, even inhumane, working conditions. It is in the nature of organizations to keep asking for better performance, but it is the practitioner’s personal responsibility to decline inhumane demands (Lyall, 1989). The antidote is good, old-fashioned boundaries: assertively notifying management of the excessive burden and unreasonable pace.
• “No” to giving up your personal time and lunch for non-urgent matters.
• “No” to referral sources who request that you perform activities, such as child custody evaluations or hospital consultations, that you do not desire to perform.
• “No” to managed care organizations that undervalue your services and pay egregiously low rates and require extensive, unreimbursed paperwork.
• “No” to the industrialization of mental health care that attempts inappropriate incursions into the psychotherapy you offer.

Let us be crystal-clear here: We are not advocating remaining entrenched in old therapy models or avoiding newer, briefer treatments. On the contrary, it behooves us all to keep updated on more effective and efficient means to alleviate human suffering. What we urge you to avoid is practicing in ways you do not believe in – ways that undermine your ethics and integrity – since they add inordinate stress and compromise patient care (Bromfield, 1996). For example, our ethics and integrity are assaulted by adopting a purely medical model, overemphasizing DSM or ICD diagnoses, losing track of the human relationship, and employing “any willing” licensed therapist.

Say “no” as a matter of integrity. The cost to your soul is simply too high.

Many psychotherapists experience difficulty in asserting themselves and in setting limits in professional settings, particularly with their clients. They are, after all, helpers and advocates. The research shows that therapists with unassertive styles are more prone to stressful encounters in the psychotherapy process (Zeeck et al., 2012). Just as our unassertive patients experience more stress and avoidance in their lives.

Phrased more positively, assertively maintaining boundaries means remaining true to yourself, your moorings, and your vocation (Norcross, 2005). Relentlessly define who you are and what you do. Know and accept your limits.

A workshop participant writes that “I am working very hard to realize that I cannot take care of others until I take care of myself. But what has become clear to me is that my job – the one that sent me to your workshop – does not really want me to set boundaries. They only want me to work 20 hours a week, but that translates into them wanting to pay me for 20 hours a week but they actually want me to work 37 to 40 hours a week and not pay me. When I set boundaries with them, they get pissed.” Boundary maintenance frequently begets indignation and surprise from those habitually violating those boundaries!

Speaking of limits, we enthusiastically recommend that psychotherapists more frequently transfer difficult cases – for a second opinion or another evaluation or the entire treatment – to a colleague (Kaslow & Schulman, 1987). A transfer is indicated whenever the case becomes prolonged, inefficacious, a poor client-therapist match, or a shaky therapeutic alliance. And all ethics codes prohibit us from practicing beyond our sphere of competence and remind us to consider transfer whenever services are not proving successful. In addition, transfer should be considered when the patient’s struggles and circumstances are too similar to the therapist’s life. The terminal illness of a close family member, a recent death or divorce, or the chronic illness of a child are prominent examples. Nonacceptance or transfer of patients at such times “represents a sensitive and humble awareness of one’s limitations and the placing of the patient’s needs for efficacious treatment above one’s own for a busy therapy schedule” (Kaslow & Schulman, 1987, p. 92). Such transfers can rightfully be interpreted as a sign of strength and wisdom, not failure; of placing the patient’s welfare over the therapist’s psychological esteem or financial interest.

Maintaining proper boundaries means not only saying “no” but also saying “I don’t know.” It’s honest, avoids defensiveness, and confronts your perfectionist tendencies head-on. We simply cannot know everything!

Defining Relationships with Colleagues and Staff

Just as it is essential to communicate and maintain the boundaries of the treatment relationship, it also proves useful to clarify your relationships with colleagues (Tabachnick et al., 1991). All therapists experience a number of potential role relationships with colleagues: In some cases, we assume the role of peer, and in other cases, we behave more like a parent, rival sibling, or friend. Obviously, this process is not restricted to psychotherapists; it is true of all work relationships. However, the emotionally rich and psychologically potent world of psychotherapy exaggerates the problems normally encountered with colleagues in a work context.

This phenomenon becomes particularly acute when the roles are compromised by a blurring of boundaries (Slimp & Burian, 1994). For example, it is universally recognized as unethical for a clinical supervisor to become a lover of his or her supervisee. The role of supervisor or colleague also generally precludes the formation of a personal psychotherapy relationship with supervisees. In some cases, the administrator of a clinic may find it difficult to assume the role of peer and friend as a result of the power differential associated with his or her “parenting” role.

Psychotherapist-staff relationships also become tricky and strained if boundaries are not maintained. Staff are part friends to psychotherapists, part of the clinical team, and yet frequently employees or direct reports to psychotherapists. The blurring of roles and the relationship elements frequently confuses staff members not formally trained in graduate coursework. We and others have found it useful to take an hour periodically to discuss openly the therapist-staff relationship.

Such relationships can be further strained when practitioners delegate nonclinical duties to staff, who frequently experience it as “getting more work dumped” on them. Psychotherapists are wise to delegate such tasks and to free up their time and energy to concentrate on what they uniquely do best. Indeed, we encourage you to delegate all nonclinical work such as filing, word processing, scheduling appointments, creating websites, billing, and related office tasks. Even if you personally pay for it, delegate to others whatever runs counter to your skills and interests. See an extra patient per week and eliminate three hours of drudgery.

Defining Boundaries with Family and Friends

Family and friends are not usually direct participants in the professional world of the clinician. They are not present during psychotherapy sessions, they do not meet clients, and they do not assist with the delivery of services. Confidentiality requires that the clinician not share the identities and disclosures of clients with them. This leaves family and friends outside of the clinical experience of the practitioner.

One of our master psychotherapists described it this way:

“My kids don’t really know what I do for a living. It’s hard to explain it to them, and I can’t really show them. They’ve seen the office; they know I talk and listen to people who are unhappy or have problems. But they really can’t understand why I get paid for this. After all, I do the same for them at home all the time … and not always effectively!”

Without considerable effort, there is little opportunity for spontaneous phone calls, personal visits, and short breaks with friends and family during the typical workday. The clinician spends most of her time with clients, many of whom are in distress. Moreover, since the focus on the client is often intense and engrossing, there is little opportunity for the therapist to think about personal relationships during a long day at the office.

Find ways to bridge this gap without compromising ethics. Deliberately schedule lunch appointments and visits with friends and family during the workday. When possible, telephone loved ones between appointments. Brief mindfulness breaks help too.

Setting Boundaries Away from the Office

In order to effectively disengage and leave it at the office, psychotherapists must establish clear boundaries outside of the office. Like other employed humans, mental health practitioners struggle to strike a happy balance between work and home life.

One of our master clinicians commented in an interview:

“I make it clear that I keep clinical work in my office during my workday and try not to bring it home with me. I avoid talking about what’s happening in my clinical work with my family or with other people, feeling that family time is family time and leisure time is leisure time and work time is work time. I set those boundaries in my own mind to try and keep clinical work in the office.”

Establishing secure boundaries maintains some distance between a therapist’s personal life and professional life. Doing so will require a thoughtful delineation of the roles of several significant people who populate the world of the practitioner, beginning with the therapist herself.

The Psychotherapist Outside the Office

It is not enough to know “who you are” at the office; you must also know who you are when you’ve left and gone home. To be a friend, spouse, parent, or lover, you must set aside the interpretive stance – the sometimes aloof and distant perspective of the “observer” – and enter into genuine relationships. You must also set aside the travails of conducting psychotherapy. Those working with patients suffering from severe psychopathology, in particular, struggle to leave it at the office, although their patients remain imprinted in their memories and even intrude into their personal lives through emergencies and patient-initiated contacts outside of the session. Thus, it is probably not realistic to speak of always “leaving it at the office.” Instead, it is more realistic to set boundaries and to modulate the intensity of therapist response to such work (Kaslow & Farber, 1995).

For many of us, this is easier said than done. Most of us admit that we are prone to overextension of work, and we need to make conscious efforts to construct boundaries to help us help our patients. To some extent, this is the price of socially defined success in our culture, but to some extent it also reflects some clinicians’ characterological vulnerabilities. Those suffering from the central character trait of the selfless caretaker (Barbanelli, 1986) minimize their emotional needs in deference to the needs of others. Some psychotherapists “need” to be needed. Always giving, but in the end, typically feeling deprived, isolated, underappreciated, and lacking a meaningful life outside of the office.

Significantly, the work-related distress of psychotherapists is not necessarily related to the number of their client contact hours (e.g., Firth-Cozens, 1992; Kramen-Kahn & Hansen, 1998; Orlinsky & Ronnestad, 2005; Sherman & Thelen, 1998; Rupert et al., 2013). Thus, the common suggestion to cut back on the number of clients or reduce patient contact is not a panacea. Instead, one needs to selectively cut back and diversify one’s activities by doing other things.

All activities create stimulation, variety, and fresh challenges. Teaching, supervising, consulting, performing assessments, conducting research, writing articles and books, or working in entirely different settings all allow practitioners to define themselves as someone other than simply a psychotherapist. This same outcome can also be accomplished by pursuing parallel career interests outside the field, related or unrelated to psychotherapy.

Creating a broader definition of who you are as a professional enables you to perceive yourself as more than a psychotherapist. Many colleagues acknowledge that doing so makes it easier to set aside the role when they leave the office (Guy, 1987). In fact, several of our master clinicians enthusiastically shared the value of pursuing other interests and activities, including teaching, research, media appearances, and writing. Out of our list of 19 self-care strategies, pursuing interests outside the consulting office ranked as the fifth most important. Clearly, many of the happiest and most successful psychotherapists have found that it is best to define themselves professionally rather broadly by pursuing a host of roles in addition to that of psychotherapist.

One master clinician related the following during an interview:

“Other professional activities help alleviate the stress of my practice. They take me one step back from the therapy process, and I can then see the big picture without getting lost in the details. It’s also nice to function as a professional without feeling the pressure to do something about an urgent problem. I find that this helps to clarify my thoughts and provides a more relaxed opportunity for me to be creative.”

For you to successfully set aside the role of the psychotherapist, you need a personal life that must have meaning and joy outside of the healer role. Give careful consideration to your investment in pursuits that are independent of your work as a psychotherapist.

Clients Outside the Office

Earlier, we discussed the need to carefully define the relationship between the client and therapist within the psychotherapy encounter. The focus then was primarily on the contacts that would occur within the context of the consulting office. We now consider contacts between client and therapist that might occur outside the office.

A concrete start is to demarcate work from home by developing a transition or decompression ritual. It convincingly marks the transition from work to non-work. Representative rituals include sitting quietly for a minute before leaving for the day, saying a brief prayer, listening to relaxing music on the way home, spending some time alone reading, meditating for several minutes, changing clothes, and exercising (Mahoney, 2003; Neumann & Gamble, 1995). A psychiatric nurse attested that “I have found building in and safeguarding my transition ritual to be sacred! I am so thankful for it. It helps me decompress immediately after my shift, and it allows me to have time to myself to clear my head, refocus, and unwind.”

One master therapist relayed her daily transition ritual:

“As I walk from the car to the front door, I say to myself, ‘My work is over, my stress is behind me. On the other side of that door are the people I love most and who love me.’” You may require an act or action to formalize the physical and emotional transition and to build a new presence (Geller, 2017).

Most ethics codes explicitly acknowledge that not all multiple relationships are unethical; however, multiple relationships that would reasonably be expected to cause impairment or risk exploitation or harm are deemed unethical (e.g., American Psychological Association, 2010; Zur, 2007). The intent is to strike a fair balance between benign and potentially therapeutic dual relationships, on the one hand, and blatantly exploitative relationships, on the other hand. The exact line here is murky and mired in professional controversy (see, e.g., Epstein, 1994; Lazarus & Zur, 2002), but the essential point is that most dual relationships must be avoided in order to protect the client and the integrity of the treatment relationship.

Concretely, this means that the client and the therapist will not pursue a relationship beyond their professional one. They will not meet together for other purposes, such as friendship, business, or romance. Having agreed upon this fact, there are still matters to discuss. Can the client call the therapist at home? Can she appear there for assistance? Will she meet individuals from the psychotherapist’s personal life, such as a spouse, children, or friends? If the therapist and client should meet inadvertently outside of the office, should they acknowledge each other and talk casually (Sharkin & Birky, 1992; Zur, 2007)? To what extent will the client have access to the personal life and relationships of the psychotherapist?

Sadly, some clinicians experience difficulty in maintaining appropriate boundaries. They cross the boundaries themselves by making unnecessary phone calls to clients, sending letters or notes only vaguely related to the therapeutic work, or arranging to meet outside of the office for supposedly “psychotherapeutic” reasons. These behaviors blur the roles and boundaries, with detrimental consequences for both the client’s treatment and the private life of the psychotherapist.

Of course, more times than not, patients initiate the multiple relationships outside of the office. For patients with mild or solely Axis I disorders, gentle but firm reminders about the treatment contract will suffice to stop future contacts. But for patients with severe and Axis II disorders, more persistent efforts may be required.

One of our studies focused on protective measures taken by psychotherapists to ensure their safety and that of their loved ones (Guy et al., 1992). The top five measures were to decline to treat certain clients; refuse to disclose personal data to patients; prohibit clients from appearing at your home; locate the consultation office in a safe building; and specify intolerable patient behaviors. Other measures, as needed, should also be considered: Avoid working alone in the office, install an office alarm system, obtain training in handling assaultive patients, and so on. The objective is to protect yourself and your life outside of the office.

Colleagues Outside the Office

The practice of psychotherapy can easily absorb the entire life of the practitioner. It is a job – but more of a calling than a mere job. Some psychotherapists prefer to “live” the job without interruption. In effect, they lose themselves in the persona of the psychotherapist or hide themselves in their patients’ lives. They are invariably “on duty.”

Of course, some blurring of private time with professional work proves inevitable; the line between people’s work and non-work lives continue to blur in all professions. Almost half of working Americans say they take care of personal or family needs during work, and about a quarter report that they regularly bring work home and work during vacations (APA Center for Organizational Excellence, 2015).

Some psychotherapists, however, take it to extremes. Their social events typically revolve around conventions, workshops, retreats, supervision groups, and book discussion groups that focus on psychotherapy. Gatherings become meetings rather than parties. Colleagues become the primary, if not the only, friends of the practitioner. This blending of worlds is complete when the psychotherapist never has to stop being the clinician.

This characterization is frighteningly too close for comfort for many of us. What percentage of your close friends are fellow mental health professionals? Your last non-conference vacation was when? Do dinners and parties frequently devolve into shop talk? Does your partner/spouse decline to attend gatherings and outings because they inevitably turn to work discussions?

Consider whether colleagues in the profession have become the primary players, or even sole participants, in your private life outside the office. It will prove extremely difficult to alleviate the distress of this profession, or maintain a balanced life, if there is no escape from professional colleagues who have become your only friends.

In Closing

At the beginning of this course, one of our workshop participants captured the essence of the dialectic between therapist self-care and clinical responsibilities. “How can I cut my hours down to 40 and walk away feeling justified? … Can I say ‘no,’ ‘enough,’ ‘good enough for now’ and still feel professional, effective, and ethical?” The incontrovertible answer is Yes! But it takes considerable work to establish and maintain that delicate balance.

We advocate a mature synthesis to the dialectic of selfishness versus responsibility (Gilligan, 1982). Namely, define yourself, acknowledge your limitations, take control of your life, balance competing demands, and take an active stance toward your choices. In two words: “set boundaries.”

The observation that therapists do not necessarily practice what they preach also applies to boundaries. One therapist (Penzer, 1984, p. 52) whimsically observed:

“We [psychotherapists] seem to possess our own unique brand of craziness seemingly endemic to and epidemic in our profession. Although not clearly identified in DSM-III, our dysfunction involves the promotion of wellness philosophies, goals and strategies, while imbibing homemade anti-wellness potions.”

Top among the potions are short-lived boundary commitments, such as “I’m only going to work two nights a week,” which have as little chance of implementation as a New Year’s resolution. Like the diabetic physician who repeatedly fails to take her insulin, many of us fail to implement our own boundary advice. Some observers (e.g., Gladding, 1991) go so far as to label these boundary problems as therapist “self-abuse.” Examples are practitioners who schedule too many clients in one day or who let clients consistently run over the allotted session time.

The probability of therapist impairment, particularly as it relates to client exploitation, is decreased by the clarification and strengthening of therapist boundaries (Gutheil & Brodsky, 2011; Skorupa & Agresti, 1993). The clinician who understands her role, and that of the client, will make better decisions regarding contacts both inside and outside of the office. She will better resist compromising the treatment relationship by encouraging other agendas, such as profit, companionship, or romance. Honest scrutiny is more likely to occur within caring relationships with loved ones than within the work environment, where clients and colleagues have a wide variety of motives that make disclosure difficult or unwise.

Our ardent hope in this course has been to argue for multifarious manifestations of ethical boundaries inside and outside the office in a manner that informs, fuels, and guides your self-care. Make no mistake: Such boundary work takes considerable energy and deliberate commitment on your part. And it will entail careful attention to the nature of your relationships inside the office – with patients, colleagues, staff, and family – as well as outside the office with those same groups of people. Cherish and protect your boundaries – essentially, your personal space and self – in order to provide optimal care for your patients.

Self-Care Checklist

• Understand concretely your roles, responsibilities, and limitations as a psychotherapist; only then can you share and establish these boundaries with patients.

• Work under capacity (90%) so that emergencies, family demands, and self-care can be routinely accommodated.

• Be explicit with your clients about your professional expectations and limitations. Setting boundaries emerges in our research as the most frequent self-care strategy of mental health experts.

• Secure informed consent and goal consensus in a collaborative manner with patients early on in treatment to avoid subsequent boundary misunderstandings and confusion.

• Clearly delineate your policies regarding extra sessions, late appointments, out-of-session telephone contacts, payment for services, and the like.

• Consider adopting an informed consent form as a written treatment contract.

• Establish a monitoring method to determine when a particular boundary has been crossed.

• Cultivate shared responsibility with patients for the change process and treatment outcome; avoid taking sole responsibility for psychotherapy.

• Craft your own professional bill of rights. What are your inalienable rights as a psychotherapist?

• Demand a livable wage and a “good enough” income; you can do good while doing (financially) well.

• Set caseload boundaries: Maintain your caseload at an effective number for you and limit the number of high-risk patients at any one time.

• Minimize your out-of-session exposure to emergencies and patient incursions into your personal time.

• Take protective measures to ensure your physical safety and that of your loved ones. Decline to treat certain clients, refuse to disclose personal data, prohibit clients from appearing uninvited at your home, and make your office secure.

• Learn to say “no” to clients, referral sources, agencies, and administrators; become a responsible, assertive therapist.

• Rebuff inappropriate incursions into your practice by managed care organizations and other entities that would compromise your integrity and ethics.

• Delegate nonclinical work to staff or external services; focus on doing what you uniquely are trained and interested in doing.

• Be clear about post-termination contacts with clients. Saying good-bye to clients properly requires explicit statements concerning how, when, and why treatment may resume in the future.

• Beware of avarice. Are you working long hours out of financial necessity or because you are getting greedy?

• Bridge the gap between work hours and your loved ones by building in phone calls, personal visits, and short breaks.

• Demarcate the transition from work to non-work with regular rituals, such as listening to music, exercising, changing your clothes, or meditating.

• Transfer difficult patients – for an evaluation, a second opinion, or for treatment elsewhere – from a position of strength.

• Remember that your clients are not there to meet your needs; treatment relationships are not reciprocal.

• Define your relationships with colleagues with care. Transference influences these relationships too.

• Let your hair down with family and friends. They want you to be genuine, spontaneous, and unprofessional.

• Establish an identity and life apart from your psychotherapist role. Don’t get stale!

• Zealously protect your personal time with family and friends; work is work and home is home.

• Avoid friendships exclusively with clinical colleagues, as social gatherings with them may quickly deteriorate into work meetings.

• Embrace a mature synthesis of the dialectic between commitment to self and commitment to patients. Be both connected and separate through realistic boundaries.

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