Counseling Today, Online Exclusives

Primum cura te ipsum: First, heal thyself

By Samuel Kohlenberg August 17, 2020

During this bizarre and painful epoch beset by pandemic, racial trauma and social injustice, there is a growing emphasis on clinician well-being and self-care, and rightfully so.

Countless articles and blogs have been written about self-care for counselor clinicians, and here is one more. Why write another one? Because as a counselor educator and supervisor, I want to sell you on a goal other than being OK enough to work. Because avoiding burnout is not enough. We need to set the bar higher to competently render care. Make no mistake, this is an ethical issue.

Like many, perhaps, I have always found Latin venerating in a way that underscores the importance of a phrase or idea. Whether carved into cornerstones or encircling university seals, the tradition has gravitas. One idea I find worthy of such reverence, as it pertains to psychotherapy and behavioral health, is that clinicians need to “do their own work.” Therapists need to heal.

Whether it is through traditional talk therapy or other means, therapists need to attend to their own trauma, developmental journeys and growth. While the oft-cited phrase attributed to Hippocrates, “primum non nocere” (first, do no harm), is a vitally important doctrine in mental health, I am suggesting that there is an overlooked and more sequentially vital step in terms of primacy required to avoid doing harm: that therapists confront and deal with their own issues.

Although therapists are often told that they need to take care of themselves and “do their own work,” I do not believe there is enough understanding regarding why this is so crucially important. Yes, it benefits the therapists, it may mitigate burnout, and it may increase professionals’ longevity in the field. But from my perspective, not enough emphasis has been placed on the idea that people who are not OK do not make competent therapists.

This is not to say that people who have endured trauma or have previously met criteria for a behavioral health diagnosis should not pursue jobs as therapists. Far from it. Many of the best therapists I know are as good as they are in large part because of the difficult roads they have had to walk.

There are many ways to describe how therapists doing their own work might affect them professionally, but I am going to focus on three ideas:

1) Your nervous system is an instrument for attachment work and relationship, and it is shaped by how much work you have done.

2) Doing your work helps you project less and become more aware of your projections.

3) Having done the work means being able to genuinely relate to what your patients are going through instead of just understanding. (Note: Although I say “patient,” please feel free to substitute “client.” The reason I prefer patient is that I feel it better emphasizes the connection between the physical and psychological realms, and given the field’s current understanding of the interconnection between the two, I intentionally use language that fits in both lexicons.)

The nervous system

In a typical stress response, a perceived threat can activate the amygdala, leading to the release of epinephrine and coordinating a sympathetic response to the stressor. Typically, this sort of sympathetic activation means that you are no longer using the circuits associated with optimal social engagement (consider, is it harder to tell how other people feel when you are angry?).

The social engagement system is characterized by the feeling of social connection, the ability to read social cues, eye contact, voice modulation and comfort. All of these things shut down when we go into sympathetic activation as part of a stress response.

Imagine a therapist who has yet to “do their own work” sitting in their office listening to their patient describe a traumatic event. Even if an activated therapist gives no obvious facial expression or gesture, how do you think the person sitting across from them will be affected by the therapist’s nervous system switching gears from social engagement to fight-or-flight?

Imagine for a moment a scared child running to a parent or caregiver and being met with warm eyes, a soft smile and a soothing voice. Now imagine the same child being met with scared eyes, decreased facial muscle tone and a flat voice. In which situation is the child going to be more OK?

Similar dynamics play out in therapy. This means that therapists’ ability to stay in their social engagement system affects patients’ likelihood of being OK while doing things such as trauma work. Part of a therapist’s work is using their nervous system to help resource a patient’s nervous system. For some, it will take significant and ongoing work to be able to do this well. 

Awareness

Awareness and projection share a simple relationship: The more aware you are of your projections, the less likely you are to inadvertently allow those projections to affect your relationships with others.

Regardless of theoretical underpinning, modality or clinical philosophy, virtually all types of psychotherapeutic work regard the relationship between therapist and patient as instrumental. Thus, if the therapeutic relationship itself is one of the primary means by which therapists ply their trade, and a lack of awareness can lead to one’s projections interfering with relationships with others, there is an argument to be made that therapists are on ethically dubious ground if they practice without having cultivated enough awareness and done enough work to overcome this potential pitfall.

You are missing your patient if all you can see is your projection. You are not going to realize that it is a projection if you have yet to cultivate enough awareness. 

Relating

There is a difference between understanding what someone is going through and being able to truly relate to it. While psychotherapists are undoubtedly an empathetic bunch, helping someone engage in the process of developmental therapeutic growth beyond where you yourself have grown is no easy task.

Imagine for a moment a 40-year-old in the midst of an existential crisis. Now imagine an empathetic and well-meaning 14-year-old attempting to help that 40-year-old. Unfortunately, a developmental stage is not always as clear as chronological age, and this can lead to blind spots for clinicians that may negatively affect quality of care. Being able to genuinely relate to what your patients are going through is important, and the 14-year-old is going to have a heck of a time helping the 40-year-old.

Keep doing your work

The thing that all of the above ideas boil down to is relationship. It is your job to ensure a helpful clinical relationship, and the relationship itself is the greatest clinical tool that you have. Ensuring that this primary tool is going to be functional, let alone optimal, can require time, effort and a willingness to endure the discomfort necessary for growth.

Of course, more basic day-to-day self-care is still important for fighting burnout and for resourcing one’s self, especially when you are tasked with taking care of others and especially during times in which nobody seems to be OK. The invitation, the challenge, the mandate, is to not stop at “resourced.”

Aim higher. Embrace catalysts for growth and development. Get comfortable with discomfort when it means a potential breakthrough. Do it for you. Do it for them. Do it like it’s your job.

 

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Samuel Kohlenberg is a clinical psychophysiologist, licensed professional counselor and behavioral health educator specializing in the treatment of stress. He is a master of education in the health professions fellow at Johns Hopkins University and a postdoctoral fellow at Saybrook University and works in private practice in Denver. Contact him through his Facebook page or through his website at denverstressclinic.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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