The Whole Truth: Coping Creatively with the Dark Side of Therapeutic Practice

Earn CE Credit

• Confronting the Dark Side
• Finding Support
• Taking Off the Mask
• The Therapist as Artist
• At the End of the Day
• Suggested Activity
• References

We are sitting down to dinner, like we do every night. My oldest son, home briefly from college, has reclaimed his seat to the left of me. Across from me sit my other two children, sweaty and satisfied by their after-school sports practices. The four of us chirp out a collective, “Thank you,” to my husband, the cook, for such a good dinner. We eat and talk and wind down our day.

Only moments before, I was finishing up one of those long, intense days, hour after hour filled with client struggle and crisis and touching connection. I had silently shooed my last client out the door, my thoughts becoming a bit frantic when I thought she was going to stop at the bathroom, further delaying my departure. I swooped out—lights off, sound machine off, alarm set—hurrying to get on the road that would take me to my daughter’s soccer practice just in time to pick her up.

Most days are like this. I dive deeply into my commitment to healing and helping clients. I work with their internal worlds, and willingly make contact with some of the most painful aspects of life. And, just as quickly, I rush up from the depths, back into daily living.

Today was more difficult than average. A long-term client came in with the news that she’d been diagnosed with an aggressive form of cancer. A 15-year-old who had been successfully using art as an alternative to self-harm arrived to session with a freshly cut X in her shoulder. I struggled to engage a new client—a sullen, depressed teen. I listened patiently to a client tell a different version of the same story about her frustrating husband. And I hosted a culminating art show (both celebration and termination) with the work done in treatment by my client, a recovering addict, for her and her large extended family.

Yet when I sit at dinner now with my own amazing family, there is nothing to say in reply to my kids’ inquiries: “How was your day, Mom?” I can’t give them details; everything is confidential. Besides, it feels impossible to convey the depth of pain and joy that my job delivers. And while I think they are actually asking, “How are you, Mom?” I haven’t even had the time to figure that out. Between racing out of the office to soccer practice pickup, and then home for dinner, there hasn’t been an ounce of room for self-reflection. And if I use the time at dinner to really see how I am, I know I will come up with confusing and disparate adjectives: drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad. The truth is I’m full of joy and gratitude for the opportunity to midwife significant changes in so many clients’ lives. At the same time, I also have my fill of others’ pain, their traumatic stories, and the experience of feeling helpless in the face of intransigent symptoms. I know too well that, if I’m not careful, this visceral awareness of human tragedy can lead me to disconnect from even the most basic dinner conversation, or worse, cause burnout at work and alienation from family and friends.

Confronting the Dark Side

I’ve come to learn that what I once held true about my profession is in fact not the whole truth. Being a therapist is not only about being effective at helping clients reach their goals. Aspiring to help clients make significant changes, achieve their treatment goals, and improve their functioning is a worthy pursuit that requires a lifetime of work and experience, but effectiveness is only part of the story.

In 2009, psychologists David Orlinsky and Michael Ronnestad studied over 5,000 therapists’ experience and careers, and brought to light the double-edged nature that psychotherapeutic work embodies. They found that, while over half of the therapists studied feel they have effective practices that yield feelings of competence, positive relational interactions, and flow states, another quarter have what the researchers deemed a challenging practice. The therapists studied were equally likely to experience this stress across orientations, career levels, and licenses. But what is fascinating is that those therapists with challenging practices—who experienced professional self-doubt, frustrations, and difficult feelings—still reported high engagement and positive relational interactions. This challenges what therapists might assume to be true: either you feel good because you’re doing your job well, or you feel bad because you are not helping your clients effectively enough. In fact, it offers an alternate view of our work: that there really is a way to experience difficulty without being inadequate, a way to hold self-doubt without feeling incompetent. Orlinsky and Ronnestad’s research reveals that while it is important to increase effectiveness for the therapist’s sense of healing involvement and for the client’s satisfaction with the services offered, effectiveness alone will not mitigate the stress of the profession. If we do pursue ideal effectiveness as our one and only buffer for professional stress, it seems we are setting ourselves up for burnout.

When I started seeing therapists as individual clients, I began to hear how easily this stressful involvement can easily turn into shame. If we don’t figure out ways to cope with the difficult feelings that accompany our work, burnout and self-doubt can begin to interfere with our well being and cause emotional disconnection from our therapeutic relationship with clients.

I’ve heard the narrative many times. It goes something like this: “I’m a therapist; I’m supposed to be emotionally healthy. But every single day, hour after hour, I have the chance to feel like a failure. Whether or not I succeed in empathizing with my clients, I feel struggle and pain and tragedy. I’m supposed to be healthy enough to withstand it. If I don’t feel emotionally resilient and instead feel bored and unconnected, or dread seeing my clients, I am a failure. But I can’t be a failure, so I will cover it all up and live with shame.” It’s a closed narrative that doesn’t provide alternative reactions to feeling stress and uncertainty.

Orlinskey and Ronnestad’s study identified a dual coping strategy as the key to therapists’ ability to sustain themselves and to stay engaged in their work. Besides the development of clinical skills, the other aspect of coping had to do with self-reflection. In order to tolerate difficulties such as the distress of feeling powerless to affect a client’s tragic life situation, or needing to regulate intense feelings in order to establish the one-way intimacy of a therapeutic relationship, therapists need to use their creativity to see the problem differently and to “give themselves permission” to experience disturbing or difficult feelings.

When I was an intern twenty-odd years ago, my supervisors coached me to practice good boundaries, and they implied that any struggles I did have with my role as therapist or career choice were due to my lack of experience, my unresolved personal issues, or the fact that I wasn’t seasoned enough and didn’t know how to “leave it at the office.” In his book, A Perilous Calling: The Hazards of Psychotherapy Practice, Michael Sussman suggests that the original blank-screen approach to the therapeutic task has dangerously infiltrated modern practice: “Throughout the history of psychotherapy, the personhood of the practitioner has been all but ignored. Successive generations of therapist have received and, in turn, passed along a professional culture that often leaves little room for the clinician’s humanity.” My own experience as an intern mirrors Sussman’s warning: I didn’t feel I was allowed to have personal feelings about my professional work as a therapist, but these feelings didn’t stop rising to the surface. Yet, because I didn’t have a safe place to bring them or a way to work through them, I also couldn’t let myself acknowledge their looming presence.

According to psychologists John Norcross and James Guy, 75% of therapists complain that work issues spill over into their family lives. Norcross and Guy highlight the fact that increased work stress is related to decreased marital satisfaction: the emotional exhaustion of our work can leave us too tired to engage in family relationships. One might think that we therapists could just share our work drama and download to our spouses like any other stressed professional would. But confidentiality rules prevent this from happening. Besides, if we don’t understand that powerlessness and uncertainty are difficult feelings that we need to learn to allow, and instead feel inadequate for having these feelings, we are even less likely to be able to share with family or colleagues how very hard our work is.

Having weathered two decades of this amazing vocation, it’s only now that I am able to turn and look without shame or inadequacy at the shadow side of this work: the part that is painful and dark and that can become toxic, breeding isolation and disillusionment. I’ve been down that path where ineffectiveness led to powerlessness and shame, where the mask of clinical expertise and emotional stability prevented me from connecting to what was true for me, where I bought into the idea that difficult feelings were a sign of inadequacy. At one time, I thought that feeling effective was a true salve against this shadow side. I was so set on being helpful, I was willing to sacrifice almost anything. I didn’t know how to use self-reflection to process the trauma and intense emotion being poured into the core of me again and again. This is the side of my work that I don’t really want to share with my family, and the side that so few of my colleagues readily admit to experiencing.

Finding Support

Ronnestad and Orlinksy found that quality of the work setting and available peer support are crucial in assisting therapists to cope with isolation and the sense of helplessness. This seems to be an obvious solution: a work setting in which supervision and peer support groups invite discussions about these issues. Given that the researchers found many therapists to value personal therapy as a tool that helps them engage constructively with clients and feel they are thriving in their work, it would seem like validating these messier and darker inner-world experiences should be a regular work practice among colleagues as well—not just one hidden away in the private realm of individual therapy.

Certainly, there has to be a time and place for this kind of activity. When working directly with clients, we need to exercise appropriate boundaries. We don’t want to be processing our internal experience to the exclusion of tending to our clients’ experiences. But even when I invite fellow therapists to talk about and reveal their inner worlds in a safe non-clinical setting, they have a hard time doing it without relating it back to some kind of analysis of countertransference. We are so good at trying to understand our clients that even the act of excavating our inner experience of being a therapist becomes another avenue for more insight about our clients. So often I hear therapists report a feeling like irritation, and then immediately justify their irritation with a countertranference explanation about how their client reminds them of a mother-in-law, for instance. I have to ask: when can your inner experience of irritation simply be a by-product of being a therapist?

If, as Ronnestad and Orlinsky’s research suggests, nearly half of therapists feel pressured, overwhelmed, anxious, and trapped at least occasionally in session, why don’t we take these feelings more seriously? Why can’t we be open about them with ourselves and with colleagues—collectively honoring both the light and dark of our profession? Can we allow our knee-jerk therapeutic use of self-analysis to slow down just a little so that we can look at ourselves without wearing our therapist masks?

Taking Off the Mask

Just last week, in an altered book workshop that I was facilitating, I saw how sharing this inner world and this double-edged experience can benefit all who participate. The group was mixed: therapists who had been in practice for decades, a few interns, and one trainee. I invited them each to make collages that represented what they carry for themselves and for clients in their hearts. It’s always amazing to me the level of depth therapists are willing to bring to this kind of nonverbal self-reflection. The heart images were powerful and raw. One woman made a weaving that juxtaposed operating room images with strips of wholesome nature scenes. Another took large nails and screws and attached them as if they were impaling the walls of her heart. Many had innocent images of children: smooth skin, wide eyes, swaddling cloth.

In the course of the workshop, I coached these therapists about the creative process. The start of any artistic activity is always fraught with some level of fear. Sometimes the fear is so high, especially for people new to art making in adulthood, that they may have difficulty starting because they are not familiar with this line between stressful involvement and full engagement. But it often just takes a nudge to begin. I like to remind folks that they don’t have to know how it will turn out; they just have to start with a color or a brushstroke.

For the therapists I have encountered in my workshops, the first step in an art-making activity can be hard for this reason, and yet the process mirrors one all therapists are familiar with. Beginning without knowing where our efforts will end up is much like beginning a relationship with a new client, or starting a session and finding that the treatment plan has taken an entirely different direction, and things are no longer as they seemed.

Even for experienced artists, this starting can sometimes be hard, but it is also exhilarating at the most passionate level. Artists know, when they start, that if they plan too much, the process is going to be stifled, boring, and probably not very creative. If that exhilarating feeling of anxiety before the unknown is present—better call the feeling “anticipation”—it is an indicator of newness and risk, which will inevitably bring discovery of the highest order.

During the training, when we shared our images, there was a collective sigh of relief. One therapist said, “Sometimes there is a jolt of pain in my heart—the sheer rawness of it all. Who do you share this with? I could never go home and show this image to my husband. He wouldn’t understand. It’s so hard to express it honestly for yourself. But then to show it other people—I have so much gratitude that there are others who can see this, hold this, and still not judge me as inadequate.”

The opportunity to view others’ experience in a visceral way normalized the more difficult feelings that the group members carried as therapists. Hearing everybody talk about their art and the experiences that it represented allowed participants to stop pathologizing these feelings. Seeing others’ openness made the darker side of being a therapist feel more okay in a very powerful way.

In another activity, I invited the group members to make art that represented the gifts that clients had given them. They first had to get past the fear of admitting that they did actually benefit from client relationships. Then, when they were able to see how much each person’s life had been touched and changed as a result of real, concrete lessons or ideas clients had taught them, they cried. They were so relieved to see that things were actually coming in rather than just going out. One therapist would never have pursued her dream of being a professor if her client hadn’t showed her that it was possible. Another therapist credits her client with the fact that she survived cancer due to an alternative treatment approach that her client mentioned. I credit one particular teen client for teaching me how to show teens respect, and I use it every day with my own children and with all of my other teenage clients.

At the end of the workshop, after they had all made art and reflected honestly about how the profession affects their lives positively and negatively, one of the interns said that it had been an amazing gift to hear that even the most successful and seasoned therapists have difficulties in their work. She hadn’t heard about the difficulties, hadn’t seen others struggling, and hadn’t been well informed about what to expect and how to cope. The older therapists talked about the sense of validation and belongingness that the honest art expressions and discussions had allowed.

When therapists collectively allow there to be a dual experience of light and dark, abundance and depletion, there is a sigh of relief—an acceptance of the whole truth. And self-blame, inadequacy, and shame simply dissipate.

The Therapist as Artist

In the course of my trainings and also my own personal and creative life, the analogy of therapist as artist continues to take on richer, more profound meaning. Not only do therapists have amazing inner worlds that they are constantly mining for ideas, inspiration, and sustenance; to be creative, therapists have to know that anxiety, overwhelm, and uncertainty are all necessary aspects of making their art. This speaks to the idea that therapists can experience growth and depletion concurrently in their work. Just as for an artist, the therapist’s main objective becomes hanging in despite uncertainty, treating the unexpected as opportunity, seeing things from new and different perspectives, and maintaining involvement even when things get stressful. In other words, staying in flow feelings, maintaining a relational manner, and employing effective clinical skills even in the presence of stressful involvement are the ticket to being a creative therapist and staving off burnout.

Operating from the artist’s perspective, therapists can recognize that stressful involvement doesn’t have to block healing involvement. Rather, it is simply a necessary accompaniment to any creative endeavor. As Carl Rogers pointed out, constructive creativity requires openness to experience and tolerance for ambiguity: “It means the ability to receive much conflicting information without forcing closure.” The process of absorption or being wholly involved is characterized by Rollo May as “intensity of awareness and a heightened consciousness.” With this creative encounter come neurological changes—quickened heartbeat, narrowed vision, diminished appetite, loss of time awareness—that mirror physiological reactions to anxiety and fear. May suggests, however, that the artist doesn’t experience this arousal response as negative, but rather as joyful. In the creative process, flow feelings and arousal—whether experienced as anxiety or pleasure—go hand in hand. They are a result of engaging in a creative process. One without the other is impossible. The goal is not to eliminate the anxiety, but to make sure that it doesn’t block the flow.

When therapists see that their work is truly creative in nature and realize that the act of working with clients requires all the same components of any creative act, there is a built-in context for coping. How else do artists and other creatives endure their daily grind? Who else but the most creative know how to hold disparate experiences and make something of them? Just like an artist, a therapist must hold the experience of being fully, heartfully engaged to painful experiences. A therapist has to strive to connect on a vulnerable and intimate level with the client, yet maintain a professional boundary so as not to become merged in the relationship. And, despite scary or frustrating situations, a therapist must maintain engagement and strive to stay in contact with the relationship at hand.

As therapists then, we must stay creative: flexible, engaged, committed, willing to hang out in the unknown and greet newness and possibility as it comes. Be open to the process. This is not a passive state—it requires active exploration, self-reflection, sharing, curiosity, fearlessness to look at the unknown, risk taking to express that which is ugly, negative, or difficult. This commitment to staying creative must start with finding a way to communicate that inner-world experience to people who get it—to express these feelings without having to stay in the role of therapist, and to be in the presence of peers who understand that this kind of expression—can be the very key to sustaining self in our work. And because the creative process teaches us to welcome anxiety and other difficult feelings, doing art with other therapists can be a source of continual renewal.

At the End of the Day

If the creative process brings us freedom and new possibilities, it also brings us beauty. So when things aren’t seeming that beautiful around the office, when high healing involvement is giving way to self-doubt, frustration, and boredom, I’m remind myself that stress and flow are not mutually exclusive. I keep up a dialogue with myself on a daily basis. The question that I constantly ask is one that author Michael Ventura asks: “Where is the beauty in my work? Where is the beauty in this client?”

The other day, while sitting with a new teen client, I found myself melting into that beauty. She was reading a poem that she’d written as part of her therapy homework assignment. I instantly saw past her self-harm and angry outbursts, and said a deep thank you for the beauty that my work allows me to see. It’s been a long haul—from those days of meticulously monitoring client numbers and celebrating results to stepping into the quiet, reflective relationship between authentic self and work. I think I’m finally embracing that long, beautiful journey—no shell around my heart needed.

In my work with other therapists, I continue to emphasize what Jeffrey Kottler says in his wise book, On Being a Therapist: “[As therapists] we are touched by [our clients’] goodness and the joy and privilege we feel in being allowed to get so close to a human soul. And we are harmed by their malicious and destructive energy.” Having that focus, and the creative means with which to process all that comes with our work, will allow me to sustain myself and others for the long haul.

So the next time I’m sitting at dinner struggling to cross the bridge between my personal and professional lives, I’m going to consider that “How was your day, Mom?” as an invitation to take stock of my inner canvas. I’ll remember that my work is a creative process and feel more freedom in my reply. If it was one of those days, I think I will tell the kids all those disparate adjectives—drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad—without feeling bad about my work. And then I will simply say, with a smile on my face, ”It’s great to be home.”

Suggested Activity

Individually, or with a group of safe colleagues, get together to create a representation of ‘Your Doorway to Therapeutic Presence.” You can do this by using magazine images and computer paper. As you prepare, think, write, and talk about the transition that you make when you begin work in session—from the moment that marks the transition between being alone in your office to your first encounter with your client in the waiting room. Consider what you leave behind as you transition—thoughts of other clients, preoccupation with family issues, plans for the weekend, etc. And consider what you welcome—awareness, presence, compassion, openness to the unknown. We do this transition over and over again, all day long. Some days we do it without effort. Other days our responses to disturbing material in client sessions or personal tragedy cause the transition to be arduous.

As you consider your internal experience of this transition and the state of being on either side of that doorway of therapeutic presence, find collage pictures that represent your experience. For most, the feeling of being present with a client comes with pictures of broad landscape, nature, the representation of awe and the feeling of being at peace with the world. And, depending on the current life situations, the experience outside of therapeutic presence ranges from blissful faces of children to painful images that depict life challenges such as illness, death, and other real struggles.

When you are finished with your doorway, share it. Really—go ahead. This opportunity to allow yourself to be seen outside of your role as therapist by other therapists is the very thing that we are conditioned not to do. This is also one of the most important coping strategies that so many of the researchers suggest. Allow difficulties to be there, honor the intense experience, increase knowledge of self and the therapeutic process, and embrace therapy as a creative process.

References

Kottler, J. (2010). On being a therapist. Jossey-Bass.
Kottler, J. (2005). The client who changed me: Stories of therapist personal transformation (p. 1). New York: Routledge.
May, Rollo. (1959). The nature of creativity. In Anderson, H. (Ed.).Creativity and its cultivation (pp. 55-68). New York, NY: Harper and Brothers.
Norcross, J., & Guy, J. (2009, August 19). Leaving it at the office: Taking care of yourself.
Orlinsky, D., & Ronnestad, M. (2009).How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association.
Rogers, Carl, R. (1954). Toward a theory of creativity. In Anderson, H. (Ed.) Creativity and its cultivation (pp.69-82). New York, NY: Harper and Brothers. 
Sussman, M. (Ed.). (1995). A perilous calling: The hazards of psychotherapy practice. New York: John Wiley and Sons, Inc.
Ventura, M. Beauty resurrected: Awakening wonder in the consulting room.

© Psychotherapy.net LLC. Images © Lisa Mitchell.