Tag Archives: empathy

The loss of our ‘humanness’

By Suzanne A. Whitehead February 24, 2023

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Recently, I needed to undergo some medical tests in a hospital-based clinic. I arrived a few minutes early and was eventually called inside for my tests, which required four separate parts. Immediately, as I put the swaying, open-backed gown on, I began to feel my humanity slowly slipping away. I now looked like all the other patients in similar attire, and I felt the loss of myself as a human being. I started to feel like an “it” to be worked on. I had felt this way previously for other exams and tests — this was just a “refresher.”

I was prepped, injected and told to wait again; my questions went unanswered. Inside myself, I could feel my anxiety starting to well up and get the best of me. I was finally led to another room and told to lie on a table. The table was cold and uncomfortable and hurt my back, and the feeling of somehow being an “it” to be worked on, not a human being any longer, returned. I was told to raise my arms over my head, and the technician quickly left the room.

The overhanging equipment suddenly whirred noisily and began getting closer and closer to my chest and head, increasing my uneasiness. The machine rotated a bit overhead; I couldn’t see around it at all. I suddenly felt claustrophobic and a bit panicky, and finally called out for the technician after several minutes. He answered from an adjoining room and asked what was wrong.

I said I was feeling a bit anxious, asked what this test was for and asked how long it would last. He answered bluntly, “It’s for the tests you’re having.” He then aimed a fan at my head to help “with people like me,” he stated. I immediately felt demoralized again and was told it would be another five minutes under the whirring machine.

I was finally released from the “jaws” of the overhead machine. As I started to rise, I felt dizzy at first, perhaps because I had my arms stretched over my head for several minutes. I was escorted out of the room and sent back to the waiting room, again, alone with my thoughts. (It’s been my experience that human beings do not like a void of information. We try to obtain it the best way we can, and when that fails, we begin to make assumptions, which are often inaccurate. It’s simply what people do and is part of the human condition — if only the medical profession acknowledged that.)

There sat the others, all waiting for their time under the machine. I didn’t dare tell them not to worry, our eyes never meeting. Internally, I felt scared about what the tests could reveal and what else was in store. The same concern seemed etched on the faces of those in that waiting room. I wondered, “What if someone had just taken the time to explain what was happening to us and what we were about to experience?”

Taking time to connect

As I sat there worrying, waiting for my next exam, I began to wonder, “As counselors, do we take time during the essential beginning session to discuss with our clients what counseling is really all about?” Often, clients don’t know what to expect from counseling. Ours is a relatively new profession, and many clients, for example, did not even have counselors in their schools when they were growing up. Or the counselor role was so diminished, they rarely met them in person. Moreover, many schools did not even employ counselors until recently. Are we selling our clients short by taking it for granted that they simply intuitively know what to expect?

My diagnostic testing felt demeaning. With no sense of control, I felt a bit overwhelmed. In the end, I just wanted it all to be over. So, I sullenly complied with every command, didn’t ask more questions and couldn’t wait to leave. The experience — which was more psychologically than physically painful — left me with a bitter taste in my mouth, and I never wanted to return.

The parallels with counseling jumped out at me. Do our clients feel the same sometimes? Is that why many don’t want to return? For instance, according to Joshua Swift and Roger Greenberg, in a meta-analysis published in 2012 in the Journal of Consulting and Clinical Psychology, 1 in 5 clients end psychotherapy prematurely. As counselors, do we spend the necessary time to understand the culture and concerns of our clients, as well as address their fears?

Those special medical technicians who do take the time to develop a human connection first make all the difference in one’s experience. Can we say the same for ourselves as counselors? As human beings, we all crave human connection; it is the very heart of counseling. For the sake of time, are we rushing through this vital aspect of the process?

How we treat our clients

I am reminded of the many times I got extremely busy as an agency clinician and, later, as a school counselor in my own career. I would see the long line waiting at the door of our school counseling offices or sigh a bit when one of my clients finally disclosed that huge revelation they’ve been holding back the last six sessions, with five minutes left in our meeting. My heart would sink as I realized I couldn’t go over the session time because my next client was waiting. During those times, I remembered that as counselors, we are instructed not to get “too close” to our clients for fear of losing our objectivity.

Although being objective is vital to the counseling relationship and the client’s well-being, does it also mean that we must sacrifice their humanity? Sadly, I have worked with some physicians, nurses and respiratory therapists (one of my former professions) who have become cold, distant and indifferent to their patients. They have absorbed the “lesson” about not getting too close to their patients all too well and have become detached when their patients don’t respond well to their interventions or ultimately die. It allows them to not “feel” and to go on with their “routine” activities as if they were working on “machines.” Their patients know, though, and are left feeling demoralized, defeated and not heard — just like I was during my exams.

The ability to have empathy is the cornerstone of being a counselor and a counselor educator. Without this ability, we are doing our clients and students a disservice and, possibly, irreparable harm. To a degree, the ability to have empathy for the “least deserving” of our clients (e.g., individuals who have committed murder, rape or child abuse) is what sets us apart from those who are not counselors by trade. If we reject our clients for the behaviors they have committed, then we too have lost our sense of humanity for them and will judge them, harshly, just as society has.

As counselors, we never have to condone or agree with a behavior that a client has done, but we do have to see them as a human being, deserving of our care, and believe in their willingness and abilities to want to change. If we also reject these clients for the behaviors they have committed, then we have endorsed their beliefs of self-loathing and pity. We reinforce their negative self-beliefs that they are unable to ever heal and that they are undeserving of comfort, compassion and understanding. Arguably, we doom them to repeat their behaviors by our rejection, disdain and judgment. If we don’t believe in this fundamental aspect of counseling — that all persons can change and deserve our respect — then, sadly, it may be time for us to find a new career.

Finding our own balance

Not getting “too close” to our patients or clients is a self-protection mechanism. It is fundamentally a correct premise, but humanely flawed. Finding a balance between objectivity and empathy is the key. Whether we are treating patients or clients, the same premise applies. It is essential to their well-being and, I posit, to yours as well that you find your balance and always reevaluate and assess it. If you feel yourself becoming resentful toward some of your clients, or feel too rushed with them, or feel that you are becoming too preoccupied with the time spent on them, challenge yourself to be proactive to take the internal steps to work on this.

If the system needs changing, find the courage to be the voice for your clients. If working with clients in a group setting makes more sense, initiate that adjustment. If challenging the status quo requires speaking up, do so for the sake of your clients. Remember the basic tenets of your code of ethics — to always advocate for social justice, equity and cultural competence. If you need more training, obtain it. If you need more supervision, don’t be afraid to ask for it. Not only will you be following the ethical principles of self-care and wellness, but your clients will benefit from your self-investment tenfold.

If any of this resonates with you as a clinician, that is a healthy response. Human beings were not designed to be “garbage bags,” to continually just stuff our feelings until we are about to explode. If we do so outwardly, we are accused of just being too angry and emotional; when the implosion is internal, it can lead to deep and unresolved depression. No one wants to feel like they are not being listened to, are not being heard and are simply “taking up another’s time.”

If you can relate to having felt this way during a medical exam or trip to your doctor, then you can relate to what it may feel like being a client and being afraid no one will understand you. Some clients can get past some rudeness or hurriedness of staff, but they won’t do so with you as their counselor. The adage that a person may not remember everything that you say but will definitely remember how you made them feel is so true.

When we are treated as less than human, we lose our humanity. For those who do it to us, unconsciously or not, they do too. Our treatment of each other becomes rote, mechanical and unattached. The preambles to the ethics codes for both the American Counseling Association and the American School Counseling Association share the principles of autonomy, beneficence and nonmaleficence; these are essential tenets to practice our counseling craft and to live by. A basic premise of counseling is to form a therapeutic relationship of trust. It is incumbent upon all of us as counselors and human beings to always remember to do just that.

Best wishes to each of you.

 


Suzanne A. Whitehead is an associate professor and the program coordinator of the counselor education program at California State University, Stanislaus. She is a licensed mental health counselor, a retired school counselor and a licensed addiction counselor. Contact her at swhitehead1@csustan.edu.


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.

Finding balance in counseling private practice

By Bethany Bray March 25, 2021

Managing a counseling practice takes strength of both heart and mind. To succeed, private practitioners must find balance between two roles: that of the caring, empathic and client-focused clinician and that of the shrewd business owner, which necessarily involves charging fees and making money.

Most people who enter the counseling profession do so first and foremost because they feel called to help others. At the same time, many counselors harbor dreams of one day owning their own practice, and that involves handling tasks that sometimes go against the grain of their helping instincts. Charging fees to clients who skip appointments or following up about nonpayment or a declined credit card can feel unnatural to counselor clinicians, especially after they’ve spent multiple sessions listening to the person talk about the painful life challenges they are facing.

“This is a tough area to navigate for many therapists, myself included,” says Dawn Altman, a licensed professional counselor (LPC) with a practice in Bryn Mawr, Pennsylvania. “It has been my experience that the most difficult area to navigate is my own money mindset and feelings of worthiness. … Most therapists come to this field with a sheer desire to help people work through emotional difficulties and live a more enlivened life. It feels somehow ‘sticky’ to ask for money for supporting someone who is struggling. The lines become blurred between what comes naturally to most of us — helping others — and requiring payment for our services.”

Money, money, money

One major aspect of maintaining balance between the heart and mind aspects of private practice involves setting — and enforcing — rates and fees.

When she first started her practice, Altman set her fees low because she doubted her own value. “Looking back, what came up for me was what is known as impostor syndrome — that internal experience of believing that you are not as competent as others perceive you to be. This is true of so many women in particular,” Altman says. “I had to get really deep with myself and ask myself, ‘Do you fear success as a business owner more than you want it?’ The answer was, of course, no, so I had to just rip the Band-Aid off and feel the fear and bill [clients] anyway.”

Now, after years in practice, Altman has found that her caseload feels balanced when she reserves three slots in her schedule for clients who pay on a sliding scale. If a potential client requests to pay on a sliding scale and those three slots are already filled, Altman has a list of practitioners to whom she can refer the client so they are not left without options. “I find that this system works for me because I can still provide a service to those who may not be able to afford my normal fee, but I don’t get resentful that I am working for pennies,” says Altman, a member of the American Counseling Association.

Norm Dasenbrook, a licensed clinical professional counselor (LCPC) with a practice in Rockford, Illinois, believes that counselors’ ethical mandate to keep up with self-care includes financial self-care. It’s not greedy to charge what you’re worth; it’s necessary, he says.

“If I’m thinking about how I’m going to pay the rent for my office when I’ve got a client in front of me, that’s not the best care,” says Dasenbrook, who also runs a consulting company that offers trainings and workshops on managing a therapy practice. “Charging what you’re worth is the best care for clients because you’re not thinking about that stuff when a client is in front of you. We [counselors] work hard and should get paid for that.”

Dasenbrook advises that private practitioners who are starting out should ask local colleagues about their rates to find the “community standard.” From there, they should decide on comparable rates and fees and stick to them. Private practitioners should also keep in mind that most clients are not going to shop around and choose a therapist based only on their hourly rate, he says. Rather, that decision revolves around many factors, from a practitioner’s area of expertise to their reputation.

From Dasenbrook’s perspective, the business and empathic sides of private practice are not mutually exclusive. Practitioners can find ways to accommodate clients with empathy while still getting paid, he says. For instance, with clients who are having financial difficulties, Dasenbrook will work out a payment plan allowing them to pay in small installments, or he will offer them half-hour sessions for a lesser fee. In other cases, he will refer clients to local charities or agencies that offer free or reduced-price therapy. These measures all ensure that clients are treated with care and continue to get the help they need, which is empathic, Dasenbrook says.

“To me, [the caring and business sides of counseling] go together. You’re providing a service and collecting a fee. There’s nothing mutually exclusive in there. You can do both with empathy,” says Dasenbrook, who has provided private practice consultations at the ACA Conference & Expo in years past.

Counselors in private practice who struggle with the idea of charging fees should look at how other service professions approach it, Dasenbrook says. He points out that plumbers and car mechanics don’t feel guilty about charging what a service is worth, and he stresses that counselors shouldn’t either.

“Don’t lowball your fees,” he urges counselors in private practice. “Think of other professions. A cardiologist that’s just out of school charges the same as one who has been working in the field for 10 years.”

Bethany Lato, an ACA member with two office locations in the Milwaukee area, also finds that the empathic and business sides of practice management can be interwoven through intentionality and commitment to purpose.

“One way I [incorporate empathy] is by maintaining a clear vision, purpose and foundation for what my business is and who it is for,” Lato says. “When focusing on tasks such as finances, sales and marketing, web presence and long-term business planning, I tend to wear more of the entrepreneurial hat. I think about it from the business perspective: What makes the most financial and business sense in order to achieve that mission?

“From there, I circle back around to empathy: How is this serving my clients and the people that I hope to reach? Am I making sure that I am taking care of my needs while also providing care to others? By beginning my work and concluding my work from a place of empathy, I aim to find that balance and never get too caught up in the business side or in simply making money. Sometimes this comes naturally, and other times it takes a conscious effort to maintain focus on the true mission and what feels truly aligned for myself and the clients I work with.”

Caseload questions

Determining caseload size and finding the “right” number of clients to see per day in private practice is an individualized decision. Counselors must charge high enough rates and take on enough clients to make money and stay solvent, yet still keep their caseloads and daily schedules from becoming so packed that they can’t give clients (or themselves) the time and attention they need.

It’s a balance that varies for each private practitioner and one that must often be determined through experience. Kristy Crump, an LCPC in Bel Air, Maryland, continued to work three days per week in an agency setting as she began her private practice in 2014. Within a year, she was fully booked and able to leave the agency, transitioning into private practice full time.

Finding the right balance was a matter of trial and error, she says. “You have to evaluate how you feel at the end of the day, at the end of the week. I was seeing 10 or 12 clients in a day and would be exhausted and struggling to keep up. It just took time to learn what’s right,” Crump says. “Now, my balance is six [clients per day]. I have some colleagues who say, ‘Four is plenty for me,’ and others who say they can do 10. You have to figure out [a schedule] where you still feel like yourself at the end of the day.”

Dasenbrook recommends that private practitioners start with an end goal in mind when determining their optimum caseload. Do they want to maintain a second source of income, such as teaching or consulting, while operating a private practice? How many vacation days do they want to take each year? Do they want to ease into semiretirement in a few years? Once private practitioners determine their long-term goals, they can work back from there to figure out how many clients they will need to see to meet (or to leave time for) those goals, Dasenbrook says.

Developing a reliable list of referral sources is also an important part of managing caseloads as a private practitioner, Altman notes. Over the years, she has discovered that she operates best when seeing fewer than 20 clients per week. This helps her maintain balance with other facets of her life, including time spent with family and her identity as a “lifelong student.”

“I quickly found out that seeing over 20 [clients] per week does not work for me. I feel pulled in too many directions, and my family life suffers, as does my own physical and emotional well-being,” Altman says. “I am very intentional about the type of client that I want to see, and while it is hard to turn people away, I now have a waiting list for those who want to wait specifically for me, and I have a list of five or six trusted therapists in the community to whom I refer when I cannot accommodate the client. … This alone has made a huge difference to me in my work-life balance because I enjoy each of my clients, and I am not burned out at the end of each week.”

Out of whack

Bryan G. Stare, an LPC and counselor educator who has experience working in private practice, is a critic of what they call the capitalist U.S. health care industry. Many of the decisions counselors who own private practices must wrestle with — whether to see fewer clients, whether to waive fees, whether to do pro bono work — have an effect on the bottom line of their business. This is an issue that often contradicts the counseling profession’s commitment to pursue social justice, Stare says.

“You’re put in a difficult position in private practice. You’ve paid a lot of money for this education, whether it’s a master’s or a Ph.D. To live comfortably, there’s often pressure to charge more for your services. But many of us have entered this profession because of a call to help or for social justice. … It does create some strife there,” says Stare, an assistant professor and director of the clinical mental health counseling program at the University of North Carolina at Charlotte. “We need to take care of ourselves and our business to take the best care of our clients. If I’m not doing that, I’m not able to create a safe space to care for my clients. If I’m spread too thin, I won’t be able to provide ethical and competent care to clients. [But] the system isn’t designed for that; it’s a profit-driven system designed to garner corporate wealth and leave people suffering.”

Navigating this balance requires that private practitioners keep consistent tabs on how they’re feeling about their workload. Only counselors themselves can recognize when their balance is out of whack and they’re spending too much time either on business tasks or client care.

For Crump, it comes down to how she feels at the end of the workday. If she’s irritable or exhausted, it means she needs to reassess her workload. “If I’m not at 100%, I’m not helping [clients] much,” she says.

Crump acknowledges this balance got thrown off when the COVID-19 pandemic caused her to shift all of her client sessions to a virtual platform. Crump specializes in anxiety disorders, and she says some of her clients became needier amid the stressors of the pandemic. In conducting sessions and other aspects of her practice from home, the boundary line between when she was working and when she was “off” began to blur. Crump says she had to check herself and take a step back to regain her balance.

“Of course I want to take crisis calls, but I would soon find myself three sessions over my limit [for the day]. It’s a struggle because you do have that control. You can say yes. I don’t have a front desk that will say, ‘Sorry, she’s booked for today,’” Crump notes.

Stare, an ACA member who counsels a small caseload of clients in addition to teaching and research work, agrees that emotions are a barometer. Private practitioners should recognize signs of burnout and regularly process their own feelings. Stare’s support circle consists of trusted friends, colleagues and mentors with whom Stare can consult.

Multiple private practitioners interviewed for this article say their bodies give them clues — such as feeling tired, worn out or achy — that indicate their professional balance is out of alignment.

“We teach our clients to do this, and we have to listen to our own body and our own needs too, and nurture ourselves as we tell our clients to do,” Crump says. “We have to take steps back and reflect. It gets very stressful. Some days are really hard. I’m a full advocate that every therapist should have a therapist — they can help keep you in check too.”

Lato notes that somatic cues tell her not only when her workload is imbalanced but also when things are going well. When her work is in balance, “I find myself genuinely excited about my business and my practice, rejuvenated by my sessions with clients, and with vivid dreams and visions of what the business can be in the future,” Lato says. “It is that vision that often gets me through the difficult, out-of-balance times as well. I spend a lot of time journaling, meditating and vision boarding around the future of the business and my practice, and find it is always important to know where you are heading. With this clear vision and direction, it becomes easier to recognize when things are out of balance.”

Put it in writing

The counselors interviewed for this article agreed that one of the best ways private practitioners can minimize the need to have difficult conversations with clients about payment is to offer clear, thorough communication about fees and expectations before any counseling takes place.

Crump provides a full explanation of her policies in the informed consent that clients sign at intake, but she also talks the policies through with each new client before they begin counseling work. “It took me a while to get a flow to be able to speak about that to clients,” admits Crump, an ACA member. “It’s hard to say, ‘Hi, hello, I have a cancellation policy.’ … [But] if you are genuine, you’ll get that in return. When I let [clients] know my boundaries and no-show fees, I’m being honest. I explain that it’s ‘housekeeping.’ It’s important to talk about it, get it out of the way and separate sessions into counseling and noncounseling work.”

Enforcing professional boundaries, such as imposing cancellation fees on a client who repeatedly no-shows, also models healthy behavior for clients, Crump adds. “I’m teaching boundaries to all of my clients, so I want to make sure I have boundaries myself,” she says. “I make sure to set boundaries with clients from day one. I’m direct, and if I answer a crisis call in the evening, I talk about how this won’t become a regular thing.”

Yet Crump acknowledges that she still finds it hard to charge fees, even after years in private practice. It presses on her empathic reflex, she says, because she doesn’t want to discourage people from seeking counseling.

“I hate having the conversation to this day,” she says. “It’s hard because we’re in a helping role. We’re here to help, and it doesn’t feel congruent with what we’re taught. You’re imposing a boundary on them, but unfortunately, that’s part of the business. There’s no one to enforce that but me. It’s easier [when] you talk about it upfront, instead of waiting until it happens and then springing a fee on them. It’s a necessary evil that you have to do. At the end of the day, you’re running a business, and you have to pay bills yourself.”

Crump and the other private practitioners interviewed for this article say that before enforcing a cancellation fee, they usually extend a one-time grace period for clients who miss an appointment. They also make exceptions for late or lesser payments from existing clients facing hardships such as an unexpected job loss. However, they agree that charging fees to clients who are chronically late with payments or repeatedly miss appointments is a necessity.

“I will usually say to the client, in writing, ‘Twenty-four hours’ [cancellation] notice affords me the opportunity to offer your appointment time to a client who may be on a waiting list or who needs an urgent appointment. I hope you understand that I must charge you for missed appointments,’” Altman says. “Being upfront about fees and payment options is crucial in setting up a good relationship with the client and [establishes] the clear boundary that therapy is a valuable service for which payment is expected.”

Enforcing fees not only helps to ensure that a private practitioner’s finances stay in the black. It also sends a message that counseling requires commitment and intentionality from both parties — counselor and client.

“At the end of the day, if I don’t set a boundary, I may not be acting therapeutically,” Stare observes. “If we’re not meeting regularly or semiregularly, depending on [a client’s] presenting concern, we’re not going to make therapeutic gains. Ethically, I can’t provide services that aren’t going to help.”

Dasenbrook urges private practitioners to spend time crafting thorough informed consent documents. Including details such as the hourly fee for services provided outside of counseling sessions (e.g., letter writing, filing court documents) ensures that clients are fully informed prior to being charged, he says.

Language centered on client consent, privacy laws and other practice issues varies from state to state, so private practitioners should seek training and consult with local colleagues and their state counseling associations when creating informed consent documents. “These are the people who are going to know the funky laws” in your state, Dasenbrook asserts.

The language in informed consent documents needs to be thorough and firm yet welcoming and calming, Dasenbrook adds. Clients filling out these forms are seeking therapy, so they may not be in their best mental state, he points out. They shouldn’t be made to feel as if they’re doing something akin to signing the seemingly endless number of pages involved in buying a home. Breaking informed consent into sections — treatment of minors, telebehavioral health, fee schedules, privacy laws/release of client information, etc. — makes things easier for clients to digest and allows counselors to remove sections that do not apply to particular clients. Per the 2014 ACA Code of Ethics, practitioners must include information about alternative/continuing service options should the counselor experience an emergency or pass away.

Ultimately, the time spent creating thorough informed consent documents should mean fewer confrontations with clients regarding fees and other policies down the line. “The business piece [of private practice] should be all taken care of in your informed consent,” Dasenbrook says. “It should be communicated upfront, before we even say, ‘What brings you here today?’

“Put it in writing, and get it all out ahead of time. … You want to take the money piece out of it [counseling] as best you can, and that’s why [I do it] all upfront.”

Getting down to business

The professionals interviewed for this article shared the following tips and insights on blending counselors’ caring instincts with the business side of running a private practice.

>> Maintain separate spaces: Stare uses an existential humanistic approach that recognizes the importance of feelings of place. With that in mind, Stare recommends asking for and accepting client payments in a space that is separate from the counseling room. If possible, keep a credit card machine or other payment mechanisms in another room and walk there with the client to take payment. Not sitting in the same chair and in the same room where therapy takes place to accept payment helps separate the two concepts for counselor and client alike, Stare says.

>> Pay first, talk second: Crump recommends taking payment from clients at the start of a session, before any counseling takes place. Crump didn’t always follow this process but eventually adopted the approach to avoid the awkwardness of having to transition from discussion of heavy, therapeutic topics to request for payment.

Keeping a client’s credit card number on file for automatic charging can also be beneficial if practitioners find it a good fit. Dasenbrook notes that private practitioners now have many convenient payment options, including apps such as Venmo and PayPal, compared with when he started in the profession three decades ago.

>> Stay on top of housekeeping: Tackling those unappealing tasks right away can be a benefit to private practitioners and their clients. For instance, Dasenbrook says, if a client’s credit card is declined, call them right away; don’t put it off or even wait until they come in for their next session. Addressing it immediately gets the issue resolved and is more likely to result in payment.

Similarly, Crump stresses the importance of filing insurance claims and paperwork as soon as possible after client treatment. This is especially important with new clients, to find out whether the private practitioner’s services are covered or whether the client has a deductible to meet. The sooner a practice owner knows there is a gap in a client’s insurance coverage, the sooner payment arrangements can be made, especially while the session is still fresh in the client’s memory. “Even though those case notes take longer, it’s worth it [to file right away],” Crump says.

Altman notes that a tough-love approach is sometimes necessary when tackling tasks that might go against a counselor’s empathic nature. “I used to offer monthly bills, which the client could then submit for reimbursement. However,” she says, “I found that several clients would simply ‘forget’ to pay. Their bills were racking up, and I was feeling resentful over both not being paid and the time it was taking me to have to rebill every few weeks.

“One client in particular would not pay me in a timely manner, and his bill would go unpaid for several weeks. I sent multiple reminders via email that he did not respond to. When the bill was a month overdue, I emailed him the bill one final time and told him that I was unable to provide the Zoom link for our next session until he had cleared up his account. He paid the bill immediately, and at our next session, I began with [talking about] the issue of payment. We agreed that moving forward, he would simply pay weekly, which he has done since that time.”

>> Play by the rules: Crump recommends that practice owners determine their “hard and fast” rules and endeavor to stick by them. For Crump, this includes taking Friday and Sunday off each week. She blocks those days off on her client schedule. In addition, although she doesn’t mind working in the evenings on occasion, she will build time into her schedule on a subsequent morning or afternoon to catch up on administrative tasks.

Another rule Crump has established for herself is never to send a client to collections for nonpayment. “I don’t see the need to cause unnecessary harm to those [clients]. If they could pay, they probably would have. It just doesn’t feel right,” Crump says. “Also, it [collections] is just one more thing to learn how to do and keep up with.”

>> Don’t do it all: One good way private practitioners can keep from becoming overwhelmed is to wield technology to their advantage, Dasenbrook says. This includes building a practice website with client intake and screening forms that ask for a person’s home address, insurance details, emergency contacts and other basic information. This negates counselors having to spend time asking for and transcribing this information in person or over the phone.

Dasenbrook also recommends that practice owners consider using software or hiring a professional to handle administrative tasks that they dislike or struggle doing themselves. That’s what Dasenbrook does with billing. “If there are tasks that you don’t like, then hire it [out],” he says. “You can try and do it yourself at first to learn and save money, but ultimately it makes sense to hire out if it causes a headache and takes too much time. Once your practice grows, start farming some of that stuff out.”

>> Seek and value supervision: “The No. 1 tip I would offer is to spend the money for high-quality supervision,” Altman says. “I had an incredibly gifted supervisor whom I worked with when I began, and it made a huge difference in the amount of time that I had to spend ‘winging it.’ Most of our supervision hours were spent on case discussion, but sometimes we talked [about] the business of private practice. It was enormously helpful to me as a business owner. Peer supervision is another great way to connect with others to share tips and insights and to just have a sounding board for cases or for life as a therapist in private practice.”

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Necessary skills

Private practice management demands a wide variety of skills, from overseeing scheduling and billing to determining one’s caseload size and handling client referrals. A successful private practitioner must also hone a number of skills beyond the nuts-and-bolts tasks of managing a practice, says Norm Dasenbrook, a licensed clinical professional counselor with a practice in Rockford, Illinois.

Dasenbrook considers the following qualities “musts” for private practitioners:

  • Clinical competency and excellence
  • Healthy self-esteem, self-awareness and the ability to set boundaries: This involves knowing what you’re good at and what you’re not, Dasenbrook advises.
  • The ability to know when you’re over your head professionally: This involves realizing when a client’s needs go beyond your skills and that you should seek consultation. Dasenbrook has been a counselor for three decades and still runs into issues for which he seeks consultation from peers. “It happens to everybody — when you’re sitting in session and you have no idea [how to help a client]. We’ve all been there. I’ve been there many times,” he says.
  • A business mindset and inclination for bookkeeping, scheduling, keeping medical records and other administrative tasks
  • Being comfortable with taking risks: “Sometimes we fail, but we keep on going,” Dasenbrook says. “You need to see yourself as an entrepreneur. Some things won’t work out, but you learn from it and move on.”

What skills would you add to this list? Post your thoughts in the comment section of this article, below.

 

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Action steps to learn more

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Pro bono: Yea or nay?

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

What role does pro bono work play for private practitioners who are trying to balance their empathy with the financial side of running a business?

Explore this topic further in an online companion piece to this cover story, “Pro bono counseling: How to make it work.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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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.

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place — empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child’s death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn’t even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.

Defining compassion fatigue

“One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation,” Blough says. “A lot of people don’t even realize there’s a name for what they’re going through or that others are going through the same thing.”

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn’t understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn’t until she was in graduate school for counseling that she learned there was a name for what she had experienced — compassion fatigue.

According to the American Institute of Stress, compassion fatigue is “the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events.” This differs from burnout, which is a “cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related.”

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from “a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss.”

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can’t have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen — an internal boundary — that protects us, McAnally says. “Empathy, however, can be boundaryless,” she continues. “We can find ourselves overwhelmed with what the other person is experiencing. … So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion.”

As Blough puts it, “Empathy is the ability to identify with, or experience, another’s emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action.”

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.

Symptoms and risk factors

Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn’t already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

  • Feelings of sadness or depression
  • Anxiety
  • Sleep problems
  • Changes in appetite
  • Anger or irritability
  • Nightmares or intrusive thoughts
  • Feelings of being isolated
  • Problems at work
  • A compulsion to work hard and long hours 
  • Relationship conflicts
  • Difficulty separating work from personal life
  • Reactivity and hypervigilance
  • Increased negative arousal
  • Lower frustration tolerance
  • Decreased feelings of confidence
  • A diminished sense of purpose or enjoyment
  • Lack of motivation
  • Issues with time management
  • Unhealthy coping skills such as substance use
  • Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients’ levels of trauma exposure, burnout, compassion fatigue and job satisfaction.

Regulating the body and mind

“Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue,” says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one’s nervous system and the physical changes occurring within one’s body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren’t.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them — five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex — the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, “Do you notice you are gripping the armrest? Why do you think you are doing that?”

The client responded, “I wasn’t aware of it, but I find it comfortable. I feel like I’m grounding myself.”

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. “Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience,” she explains.

Creating emotional boundaries

Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say “no” to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying “no” or setting a boundary just means saying “yes” to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist’s child has a soccer game, then telling the client “no” just means that the therapist is saying “yes” to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. “Anything that helps them clear their head and allows them to be fully present for themselves or their families,” she adds.

People can also establish what Carr calls an “off switch” to help them realize that work is over. That action might involve simply shutting the office door, washing one’s hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.

Exercising self-compassion

“Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion,” Blough says. “Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder.”

In other words, self-compassion is integral to helping people manage compassion fatigue. “Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning,” Carr notes, “whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function.”

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy — ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, “I used to do it all the time before I became a professional caregiver.”

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn’t a choice they should feel guilty making.

Self-regulating in session

As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn’t sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. “If you are tense and you’re hearing all of these heavy stories, you’re at a much greater risk of being vicariously traumatized,” Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, “I’m OK right now.” As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.

Helping the helpers during COVID-19

Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, “I am falling apart. I am lost. I don’t know what to do, but sending a text to someone I trust felt right. Write or call when you can.”

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn’t in many years. He worried about his clients and feared he wasn’t doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: “Who is helping the helpers right now? How can we take care of others if we aren’t able to more easily take care of ourselves?”

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization’s aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

“Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing,” Carr says. “Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large.”

Fostering compassion satisfaction

People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn’t the case.

“I think the biggest takeaway when it comes to compassion fatigue is that it’s a normal, almost inevitable consequence of caring for and helping others. It’s not a character flaw or a sign of weakness. It’s not a mental illness. It affects the best and brightest and those who care the most,” Blough says.

For that matter, compassion fatigue isn’t something you “have” or “don’t have,” she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional’s entire day and push aside any positive aspects. That’s why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the “aha!” moment on their client’s face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these “little victories” will help renew their passion for their job, she adds.

As Blough points out, “Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It’s the joy you get from your work.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

Advice for the highly sensitive therapist

By Lindsey Phillips September 20, 2019

Erica Sawyer, a licensed mental health counselor and art therapist in private practice in Vancouver, Washington, knows firsthand the benefits and challenges of being a highly sensitive therapist. (Approximately 20% of the population has an innate temperament trait referred to as sensory processing sensitivity; individuals with this trait are categorized as “highly sensitive people.” Right after graduate school, she started working 40 hours a week at an enhanced care facility for adults with severe and persistent mental illness. She quickly realized that the constant needs in the 16-bed locked unit were overwhelming for her.

“It was very intense,” Sawyer says. “There were times I couldn’t even get out the door to take a break because there was a crisis with a resident trying to leave the facility, so we couldn’t open any of the doors. So, on my break time, I had to sit in an office where there were constant interruptions.”

Sawyer tried to escape the overstimulation by visiting the restroom, but she couldn’t stay long in there because there was only one bathroom in the entire facility and other people needed it.

On the positive side, she found she was able to connect with many of the residents in a way that surprised and baffled the other therapists. She realized, however, that being good at this type of work didn’t mean that it was a good fit for her.

In fact, Sawyer says she was on a path to quick burnout, so she determined to figure out what she could control — such as her work environment, her hours worked, and the type of clients she saw — and start making changes.

She went from a full-time inpatient position to a part-time outpatient position, but even that was too much because of the hours needed to get all the work done for her caseload of 70 people. “The quantity of clients, along with being assigned the higher needs cases, was far from optimal,” Sawyer says. “I was experiencing my own anxiety and had to go out to my car and do some tapping [therapy] to just manage the day.”

Now, Sawyer is working part time in her own private practice so that she can control the amount and type of clients she sees and the days and times she works. She also lets clients know that she can’t guarantee a response to an email after 5 p.m. Highly sensitive therapists have to recognize their stress points and the environments that aren’t conducive to their temperament because it’s not good for them or their clients, she adds.

Because highly sensitive people process more deeply, counselors with this trait may have difficulty leaving work at work, notes Heather Smith, a licensed professional counselor and an assistant professor of human development counseling at Vanderbilt University. It’s important for highly sensitive counselors not to compare themselves to counselors who do not have this trait, she says. Instead, they have to figure out their own needs and best practices. For example, they may need to see fewer clients per week or work fewer hours.

Elaine Aron lists some possible self-care practices for highly sensitive therapists on her website:

  • Practice “The Five Necessities” — believe your trait is real, reframe your childhood in light of this trait, heal from past wounds, don’t try to live like the other 80% of the population without the trait, and find a group of other highly sensitive people
  • Reduce therapy work time (ideally, no more than 20 hours a week)
  • Screen clients
  • Have downtime
  • Don’t take your work home
  • Charge clients appropriately
  • Find a good consultant
  • Seek out your own therapist
  • Take frequent vacations

Julie Bjelland, a licensed psychotherapist in private practice in California who specializes in working with people who identify as highly sensitive, recommends that highly sensitive therapists see no more than 10-12 clients per week. “You can’t see seven clients in a day as a highly sensitive person and be well because you’re taking in too much information,” she notes. Bjelland also suggests other ways that these therapists might reduce potential overstimulation and burnout. For example, they could increase their fees and see fewer clients per week, or they could see clients three or four times a week and then have three or four days off.

Smith, an American Counseling Association member who researches the sensory processing sensitivity temperament trait, advises highly sensitive therapists to create healthy habits to reduce overstimulation and to give their brains extra time to process. For example, counselors could schedule breaks between sessions, or they could make a point to finish their work notes before leaving for the day to avoid continuing to process this information when they get home. “Some of these practices can help over time to decrease the susceptibility to burnout,” Smith says.

Louisa Lombard, a licensed professional clinical counselor in private practice in California, makes a point to practice self-care habits. For instance, she takes a 30-minute break between clients so she can finish writing her notes, eat a snack, or engage in activities that she finds soothing, such as meditation or using essential oils.

Sawyer, also an ACA member, has colleagues who perform a ritual of literally washing their hands between clients as a way of letting that session and all of its associated information go down the drain before the next client.

Even though highly sensitive therapists have particular needs that must be addressed to avoid burnout, they also bring unique gifts to therapeutic sessions. Highly sensitive counselors “are well wired for this type of work,” Smith notes. “They’re going to process information more deeply. There are new research findings that suggest they have more mirror neuron brain activity and, thus, possibly stronger empathy.”

These counselors often have deep intuition and more attunement with others, and they tend to make clients feel safe and easily build rapport with them, Sawyer adds. As she points out, these qualities are “huge assets in being a good counselor.”

Bjelland, an author and global educator on the highly sensitive person, agrees that highly sensitive therapists have a lot to offer to clients because of these qualities. She finds that these therapists often have a strong connection with clients, are able to pick up on patterns and connections, and sometimes know things even before their clients do. She has had clients who weren’t able to reduce their anxiety even after working for years with other therapists. But within two to three weeks of working with her, their anxiety started to decrease.

Bjelland says highly sensitive therapists can benefit from thinking about the way that healers used to operate within a tribe: They had their own hut, and after they did their healing, they would spend a lot of time alone. “If you see one client, you’re going to need to process that session and then … rest and restore after that session,” Bjelland says. “Because if you take care of yourself well in this field, you can be a powerful healer.”

 

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Look for a related article, “Finding strength in sensitivity” in the October issue of Counseling Today magazine.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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. 

Caring vs. carrying: A therapeutic review of empathy and boundaries

By Laura Sladky July 8, 2019

“When you hurt, I hurt.” Does this adage sound familiar? No doubt, it stems from a benevolent place, but it inherently reinforces poor boundaries and misses the heart of empathy entirely.

Instead of joining in on someone else’s experience (which is not entirely possible because we do not share the exact same experiences), empathy is more akin to “You’re hurt by this.”

Empathy recognizes the feelings in each experience, names them, and honors them by listening intently with an “as if” quality — listening to another person as if this situation were their own but without making it their own. Empathy honors another person’s experience without trying to take it from them by adding on, comparing, rescuing or minimizing. In short, empathy requires boundaries.

 

Empathy is not sympathy: Empathy is often misunderstood for sympathy. By definition, sympathy is expressing pity or sadness for someone else’s situation or misfortune. Furthermore, sympathy seems to have an unspoken “Thank goodness that didn’t happen to me” undertone by association.

Although it is appropriate to express sympathy in reference to a person’s genuine loss, sympathy misses the heart of empathy because it does not approach another’s experience with an “as if” quality. Offering “I’m sorry you’re in pain” often feels dismissive and does not foster the core conditions that encourage further discourse.

Empathy is not rescuing someone from his or her experience: “If I could, I would fix it for you.” As human beings, prosocial behavior dictates that we care for others. In learning of others’ strife or struggles, there is an inherent temptation to “fix” or help even when it is not necessary.

I work in an elementary school as a school counselor. I can confirm with certainty that parents spend so much time trying to help their children (for example, by bringing forgotten homework or a jacket in case their child gets cold) that they often rob these students of the opportunity to feel and learn. In the case of the forgotten homework, students are more likely to remember to turn it in on time in the future if they are allowed to feel the discomfort of not having it once. Repeatedly rescuing someone from their experience prevents the processes of acceptance, coping and moving on that are required to fully feel an experience.

Finally, rescuing someone from their experience rather than allowing them to experience natural consequences is the picture of poor boundary setting. Empathy allows for the full and complete exploration of thoughts, feelings and behaviors, with no intent to short-circuit the process simply because we cannot tolerate someone else’s pain.

Empathy does not minimize someone’s experience: Author and researcher Brené Brown maintains that no empathic response begins with “at least.” For example, if a friend discloses that they just received a cancer diagnosis, the temptation might be to immediately highlight the good in the situation rather than holding space for their feelings and experiences toward their current situation. (“At least you have a great doctor! At least you’re able to afford the health care!”)

There is certainly a time and a place to exercise positive cognition to influence feelings and subsequent behavior. It is essential to remember, however, that active listening is just that — listening, not adding on (“Let me tell you about my aunt who had cancer”) or minimizing (“At least …”). Empathy does not absorb or modify the worries, problems, sadness or experiences of others. Empathy is standing still inside a moment, caring for another and sharing their experience — without carrying their load exclusively.

 

The science of empathy

Research suggests that mirror neurons allow us to grasp the message of and accurately respond to others. These neurons help us understand the feelings of others more accurately and approximate their experience. For example, if I see someone laughing, my brain is primed to join in alongside them, noticing the crinkle around their eyes and the upturned corners of the mouth that indicate a genuine smile.

As social creatures, we are constantly scanning one another for biological markers associated with feelings. While mirror neurons help us adjust to another’s feelings, it is important to note that, if left unchecked, we can “take on” or linger in someone else’s feelings.

 

The need for boundaries

As counselor clinicians, it is necessary for us to maintain boundaries to center the work around the client’s needs, to monitor for transference and countertransference, to attune to our worldview and how it affects the way we work with clients, to uphold ethics and to prevent compassion fatigue.

One of my favorite professors once mused that in his work with clients confronting substance use disorders, he cared about his clients deeply, but not so much that he was unable to continue to do his job. At first, I was unclear about the meaning of his statement. Now I understand that his declaration of boundaries allowed him to recognize the importance of his work without absorbing his clients’ challenges as his own to the point of burnout.

Empathy intersects boundaries in accurately understanding the experience of another without taking it on as our own. Enter the importance of self-care.

 

Final thoughts:

Author Glennon Doyle suggests, “Pain is just a traveling professor. When pain knocks on the door — wise ones breathe deep and say, ‘Come in. Sit down with me. And don’t leave until you’ve taught me what I need to know.’”

Empathy does not require pain or sorrow to be present. Rather, empathy is present whenever two individuals are together. In the fine-tuning of our responses to the thoughts, feelings and experiences of others, we are more in tune with ourselves and can better serve our clients.

 

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Laura Sladky is a licensed professional counselor intern and licensed chemical dependency counselor who currently works as a school counselor in Dallas, Texas. Contact her at l.perry09@gmail.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.