Thursday, August 07, 2008

Therapists' Burnout

James Hoyt delivered mail in rural Iowa for more than 30 years. Yet Hoyt had long kept a secret from most of those who knew him best: He was one of the four U.S. soldiers to first see Germany's Buchenwald concentration camp. "There were thousands of bodies piled high.
I saw hearts that had been taken from live people in medical experiments," Hoyt told author Stephen Bloom.
Even 63 years after the liberation, Hoyt suffered from post-traumatic stress disorder and attended a weekly group therapy session at a Veterans Affairs facility.
"Thinking back, I would have pushed to be a (psychologist) -- if for no other reason than to understand myself better."
James Hoyt, Buchenald Liberator 1925 - 2008
Retired Gen. Robert Sentman had earlier told mourners about the Buchenwald liberation. "When the prisoners saw Jim, they picked him up and threw him in the air, that's how happy they were after seeing such horrors. Prisoners had been hung from hooks to die. He saw a lampshade made from a prisoner's tattoo. Jim carried those horrors with him forever. He never got what he had seen out of his mind. If you ever wondered about Jim, think about what he saw."

The fall of Saigon drove many people into not only suicide but serious mental disorder as well. Ten years later, some physicians said that at least one thousand people around the Saigon area suffered incurable insanity on that day of the Black April. This tragedy had far reaching effects here in America too. As many veterans who could no longer endure the soul searing trauma induced by the horrors of war, and those who could no longer suffer the disgrace of defeat, took the easy way out.
Professor K. was a highly decorated war hero, and my close friend and advisor. An expert in Psych Ops (psychological warfare operations) he also conducted a major part of the counter terror program “Phoenix” in Vietnam, This CIA activity employed Special Forces personnel who were selected for their expertise in relevant skills necessary for the conduct of BLACK TERROR and assassination missions. The Project was buried deep within a Military Intelligence unit which was itself operating under the guise of a Civic Action Team, a common CIA cover for covert operations world-wide. Although members of the Civic Action team wore various military uniforms and carried on activities as though they were legitimate military officers, some were full time CIA Agents.
. I believe it was all the assassinations, and atrocities he was ordered to commit, that eventually led to his mental decline, and regretfully resulted in doctor K, drinking himself to death. Ever since my early college days, when I myself was a psychology major, I have been aware that many of my fellow students, as well as those who are now practising psychiatrists and psychologists, are more likely than any other profession, to be emotionally injured or phobic people using their occupations to heal their own psychic wounds. Alas, I have witnessed the fear of insanity, and the morbid decline of a another very close psychologist friend of over 15 years, JT, was at on time an associate professor at the same college that I attended. Before moving on to be in charge of a mental health care system covering all of Eastern Kentucky. As his brilliant mind began to fade into dementia it was like watching a slow death. To lose a good friend that way is nothing for anyone to joke about. And like the jokes deriving from the clerical sexual deviancy allegations of Roman Catholic priests. Psychotherapists are a central target of jokes and cartoons, often portrayed as greedy, out of touch with reality, easily outwitted by their crazy patients, prone to creating problems where none exist, and, of course, obsessed with sex, money, and power (Masson, 1988; Redlich, 1950). Psychologists are also accused of narcissism, over-intellectualizing, and harboring illusions of superiority, omnipotence, and god-hood. A recent surge of articles, books, and popular media focuses on psychotherapists who sexually exploit their patients. These "doctors of desire" are described as abusive, deviant, exploitative, and above all, willing to betray their patients' trust to satisfy their own desires.

In a 1952 paper, Menninger asserts his theory that most psychiatrists suffer some form of rejection in their family of origin. Hence, their work is necessary to them in order to maintain their mental health. This popular belief that psychotherapists, as compared to the general population, come from emotionally deprived or unstable homes is reflected in several papers (Burton, 1972; Ford, 1963; Groesbeck, 1975; Racusin, Abramowitz, & Winter, 1981). Groesbeck and Taylor (1977) titled their article, "The Psychiatrist as Wounded Physician," and Henry, Sims, and Spray (1973) reveals that more than 60% of the thousands of therapists surveyed report having few friends in high school and feeling somewhat isolated. The claims that psychotherapists have disrupted childhood seem pervasive; however they did not validate its conclusions.

Speculations on additional motivations for becoming psychotherapists range from therapists being drawn to "one way intimacy," to voyeurism, to obsession with others' suffering, to sadism, to an intense need to mother people (Bugental, 1964; Marmor, 1953; Wheelis, 1958). Bugental (1964) also mentions rebelliousness as a potential motivator, pointing out that the clinical setting often permits the discussion of socially tabooed topics, such as sexuality, and thereby challenges authority.

Maeder (1989), interviewing a biased sample of hostile adult children of psychotherapists, concludes, "The field of psychotherapy attracts people with a God complex in the first place, and is nearly custom designed to exacerbate such a condition when it exists" (p. 83). Throughout his book he equates psychotherapists with narcissists and uses the work of Kohut and Alice Miller on narcissistic parents to explain the dynamics of psychotherapists' families.

Studies have provided a few significant variables to indicate where psychotherapists differ from the general population or other professional groups, such as physicians. In the most extensive investigation to date, Henry, Sims, and Spray (1971, 1973) conclude from the 4,300 psychotherapists they studied that no one factor can account for these people's choices of mental health as a career. Other surveys report that prior to their choice of career, future psychiatrists tend to be intellectually flexible and interpersonally adaptive. They are apparently restless and have a low tolerance for routine. They are responsive and function well in settings where autonomy and independence are conducive to success, tend to be psychologically minded prior to their career choice, and are generally introspective. It was also found that even prior to medical training psychiatrists are significantly less authoritarian, less religious, and more liberal than their physician counterparts.

Research consistently documents physicians' significantly higher rate of depression and suicide as compared to the general population. Psychiatrists have been shown to score markedly higher than physicians. The Task Force on Suicide Prevention of the American Psychiatric Association conducted one of most extensive surveys. In investigating the deaths of approximately 19,000 physicians between 1967 and 1972, the Task Force determined that psychiatrists kill themselves about twice as frequently as other physicians. Furthermore, psychiatrists commit suicide at a younger age than the male population as a whole, and single women are at particularly high risk (Rich & Pitts, 1980). A similar survey of psychologists' death certificates concludes that female psychologists have a rate of suicide three times that of women in the general population (Steppacher & Mausner, 1974). Other important statistical data points to the high rate of alcoholism reported among psychotherapists (Thoreson, Budd, & Krauskopf, 1986).

In contrast to the above findings, Millon, Millon, & Antoni (1986) echo what many other researchers have argued; that there is no data that suggests that psychotherapists differ significantly from comparable professional groups. Indeed, no research to date indicates that psychologists and counselors are as vulnerable to depression, alcoholism, and suicide as psychiatrists were shown to be.

Though some of these conclusions are disputed, they are still valid and merit our attention. They do not necessarily mean that psychotherapists or psychiatrists manifest a significantly stronger tendency toward depression, suicide, and alcoholism prior to their training in and practice of psychotherapy. The alternative argument is that their training and practice increase their vulnerability to depression, suicide, and alcoholism. This second hypothesis leads us to the next area of inquiry.

As early as 1937, Freud warned about the dangers of psychoanalysis for the practicing analyst. In 1934 Jung alerted practitioners against what he called "psychic infection" and Scott & Hawk (1986) intensified the exploration of the hazards of psychotherapy for the therapists and forewarned that if preventative measures are not taken, burnout becomes inevitable.

My thanks to Ofer Zur, Ph.D. for doing all the really hard work. Otherwise I would have looked like a rambling fool, in trying to validate myself.


NJWT said...

Good post Walt. I think people with experience with psychic wounds will be drawn to and have an aptitude for psychology. The thing is, psychic wounds will amplify if allowed to. The best way to eliminate darkness is through light. No matter how far the practicioner comes with his or her own progress, they're daily faced with new patients bringing pathological ways of thinking to the surface. This has to be tough for someone trying to move on. Empathy is a key skill for a therapist. But what does empathy for someone else's pain do for someone who is trying to let go of their own?

Walt said...

Too much empathy can be very hazardous! Limitations of empathy can occur cognitively or emotionally. Too much as well as too little may be negative, or as with the admiration and respect, I had for my two ill fated friends and colleagues, they almost took me down with them. Colonel K, was the first to be consumed by conspiracy theories and severe paranoia. K had so many titles, doctor, professor, he was the dean of a local community college, just South of Louisville. That is before a sex scandal with a young lady, got him defrocked and divorced from a good wife of 25 years. Super men have super egos, he lost everything, but he got to keep the girl. However, with an age difference of 34 years it did not last very long. When the big K crashed, he crashed hard. When I first met Mr K, he had just got hired to work with me at the Kentucky State Employment Office. And that is a long, long way for a big fat eagle to fall. I think I saw his new wife maybe twice, before she split for good. I'm getting off track here. Hell, I had no idea, this brilliant man was on his way down and was clutching at straws, his charm was irresistible. I became his loyal friend, until one day he decided I was a spying on him for the N.S.A.