\"I've Done All The Right Things ,So Why Do I Feel This Way?\"

If you’re a clinician providing therapy, how many times today have you used the word “boundaries”? Likely in the context of working with someone in their relationships or helping someone try to get more balance in their life.

Now, in your professional context, what comes up when you think of boundaries? Maybe your ethical code and standards of practice, your schedule, client contact (or if you’re like me, always working on ending sessions on time!).  You've probably even read the articles. You might have even written one. "Ten Self-Care Strategies for Therapists." "How to Prevent Burnout in Clinical Practice." "The Importance of Boundaries for Helping Professionals."

You have likely done most of what they suggest too. You exercise, go to your own therapy, do the breathwork. You read the books, take the trainings, get supervision. You set boundaries, at least you do your best. You do what you’re supposed to do.

Then why are you exhausted?

I hear this question all the time from mid-career clinicians, the ones with seven, twelve, or eighteen years of experience. The ones who have enough clinical skill to do complex work, supervise others, and who have enough self-awareness to know something is wrong but internalize it as they are the ones doing it wrong.

What if the problem isn't your self-care?

We Are Looking At Burnout Wrong

The narrative we hear most often about burnout is that the problem, therefore the solution, lies within the individual clinician. The message is, “You're exhausted because you didn't manage your stress well enough. You need more yoga, better boundaries, a meditation app.” If the cure for burnout was more self care, all of this work would work.

But are you feeling better yet?

The research into burnout Maslach and Leiter's Areas of Worklife model (2016) identifies six drivers of burnout: workload, control, reward, community, fairness, and values. Five of six are organizational and only one is individual. Listen to Dr.Maslach speak on burnout here

A 2017 meta-analysis by Panagioti and colleagues confirmed that interventions for burnout that were directed by organizations resulted in stronger and more sustained reduction in reported symptoms of burnout versus strategies that were implemented from the individual.  The evidence is a decade old, and yet most of what is offered to clinicians is still directed at individual and not systemic change.

The system sets the individual up to believe they have failed, not that have been failed. Self-care is not a panacea, we need more.

What If It’s Not Burnout?

Using the phrase “burnout” as a catchall for every form of professional distress prevents us from targeting the actual core of the problem. What if burnout wasn’t the issue?

Burnout (Maslach et al., 1996) is chronic workplace stress producing exhaustion, cynicism, and reduced efficacy. Secondary traumatic stress (Figley, 1995) are acture trauma-exposure symptoms that mirror PTSD and vicarious traumatization (Pearlman & Saakvitne, 1995) is the cumulative shift in worldview from holding others' trauma. Moral injury (Litz et al., 2009) is distress from being required to act against your deeply held values.

These are distinct experiences that have different pathways to recovery. Burnout reponds when workplace resources increase or demands decrease. Secondary traumatic stress and vicarious taumatization needs trauma processing. Healing from moral injury works with acknowledging the harm, collective action and support, and making meaning.

When these distinct variations of occupational distress are collapsed into one word and interventions aren’t targeted, real recovery and change is bottlenecked. Having a name for your experience is not only validating, but it is also a necessary part of healing.

Where The Individual Comes In

There can be another system at play and this system is one that harms but is also rewarded, it’s like the monster feeding itself.

Schema therapy (Young et al., 2003) identifies early maladaptive schemas that shape how we interpret and respond to the world. Young also called them “life traps”; think of them as a trapdoor that you fall through when they are activate. In helping professionals, two schemas are dramatically overrepresented: Self-Sacrifice (my needs are less important than others') and Unrelenting Standards (I must do everything perfectly).

This is where the monster feeding itself comes in.

These schemas coexist with clinical wok and can be reinforced by it and the workplace. Every session rewards self-sacrifice and every positive outcome confirms: I'm most valuable when I'm giving. Unrelenting standards is reinforced when workplaces conflate overworking and performance metrics with competence.

These schemas aren’t always identified because they needs competence to stay hidden, and competence is rewarded.

When you combine the external system of structural overload with the internal system of schemas, you get a clinician who absorbs the brunt of organizational harm, gives more, performs perfectly, and then blames themself for being tired.

The cycle becomes: the system creates the wound, the schema hides it, and the self-care narrative tells you it’s your responsibility to fix and if self-care isn’t working it means you’re doing it wrong; then the system keeps pouring salt in the wound, the schemas work even harder to hide it, and you feel even worse as the cycle continues.

What Actually Helps

So if self-care is only part of the solution, what is the rest?

• Skovholt and Trotter-Mathison's Resilient Practitioner model (2016) identifies three pillars of long-term sustainability: professional vitality (meaning and engagement in the work), personal vitality (identity and relationships outside the role), and a supportive professional environment.

• What the research actually points to is co-regulation with peers (not just supervision, but genuine relational support from people who get it), congruence between your values and your practice conditions, and professional agency which is the felt sense that your expertise matters and you have influence over your job conditions.

• Rupert and colleagues (2015) found that perceived control over work conditions predicted therapist wellbeing more strongly than any self-care activity which included exercise, sleep, and leisure activities.

This doesn’t mean that you stop doing self-care activities or the things that support overall wellness, please keep doing them! It also doesn’t mean that clinicians are powerless. What it does mean, is that you have more options and different pathways beyond self-care, to help you stay in this work.

About The ReLit Practice™

ReLit Practice exists because I believe in the work we do and that clinicians deserve better than the current narrative and an opportunity to be supported.

As a part of that, I am inviting you to the Reset Circle, a free, monthly gathering for clinicians to have a space to land, connect, and share. April's theme is "Being Good Enough." and I hope to see you there!

Register here: https://www.relitpractice.com/circle