Becoming, and remaining, a therapist

Farber and colleagues asked psychotherapists why they entered the profession. The answers cluster: early experience of being the confidant in a family, personal experience of therapy, curiosity about people, and a wish to understand one’s own history. Roughly two-thirds report significant psychological difficulty in their own past.

The costs

• Vicarious traumatisation and compassion fatigue, particularly in trauma work
• Isolation — the work cannot be discussed, and much of it cannot be shared even in outline
• Uncertainty as a permanent condition; you frequently do not find out what happened
• Patient suicide, which a substantial proportion of clinicians will experience and for which most are unprepared
• The gap between the depth of the relationship and its structural asymmetry

What protects

1. 1Supervision, consistently, including when there is nothing wrong.
2. 2A consultation group or peer network with whom the difficult cases can actually be discussed.
3. 3Personal therapy — required by some trainings, and useful whether or not it is required.
4. 4Outcome data, which converts anxious uncertainty into information.
5. 5A caseload that is not entirely composed of the most difficult work.
6. 6A life outside it.

When a patient dies

Around one in four psychologists and a majority of psychiatrists will experience a patient suicide. The immediate needs are practical and personal: consult a colleague and a legal advisor before making decisions, do not alter records, contact the family carefully and with advice, attend to your own reaction, and expect that reaction to include guilt regardless of what you did. Services should have a protocol; most do not.