This paper will first attend to the hazards that the practice of psychotherapy pose to the practitioner, then to the hazards posed to the practitioner's family. The third part describes burnout and outlines how it can be avoided. The last part provides the reader with a selected bibliography on the topic. A. HAZARDS OF THE PROFESSION TO THE THERAPIST 1. Emotional Depletion: The psychotherapy profession consists mainly of working long hours in isolation. Therapists deal primarily with people in crisis and pain. They are supposed to offer these people support, empathy, interpretation, explanation, direction, or advice. They are expected to give endlessly while expecting nothing in return, except the fee. Not surprisingly, this results in practitioners' emotional depletion, in the therapists' sense that there is nothing more they can give to themselves or to anyone else. 2. Isolation: Not only do therapists work mostly in private settings, but also a growing number of laws, codes, and regulations concerning confidentiality and anonymity exacerbate the therapists' sense of loneliness and isolation. In addition therapists work when most people are off work. Their free time frequently arises during mornings and afternoons when friends or spouses are often busy. 3. Helplessness and Sense of Inefficiency: Unlike carpenters, gardeners, or surgeons, psychotherapists rarely see immediate, profound, or tangible results from their efforts. The work is often slow, and with difficult or charactologically impaired people, they may never see improvement. Even when therapy is effective in relieving painful symptoms and termination is successful, patients leave. With them goes the knowledge of the long-term effect the work has had on their lives. In addition, the lack of easily available scientific and measurable ways to evaluate the outcome of therapy, leaves therapists wondering whether or not they are being truly effective and helpful. They may question their entire involvement with what Freud called "the impossible profession." 4. Grandiosity and Omnipotence: Patients often put therapists on pedestals. They may idealize the therapists, ascribing to them super-human abilities to see, understand, and heal. In the private setting of psychotherapy, these projections may repeat themselves every fifty minutes. Combined with a lack of critical feedback from objective sources, this may encourage in clinicians the development of what Ernest Jones labeled "the God Syndrome." 5. Depression, Sadness and Vicarious Traumatization: Working constantly with people in pain, who feel suicidal, or are grieving over the loss of loved ones, or those severely traumatized, often takes a heavy toll on practitioners. The psychotherapist can be infected with a patient's sadness; a condition Jung called "psychic poisoning." The term "vicarious traumatization" has been introduced in recent years and has become even more popular after the events of September 11, 2001. Vicarious traumatization refers to the cumulative effect upon the trauma therapist of working with survivors of traumatic life events. It is a process in which the therapist's experience is negatively affected through empathic engagement with clients' trauma material. 6. Confusion: While some patients idealize therapists, others put them down. The healer may be set on a pedestal only to be knocked off of it soon thereafter. In fact, the higher the therapist is elevated, the longer the fall and the bigger the crash. Without objective feedback therapists often end up confused and in doubt regarding their own qualities, qualifications, and even their sense of worth or self identity. 7. Constant Worry: Psychotherapists often leave their offices worrying about whether a patient is going to follow up on a suicide or homicide threat. Whether or not they report such intentions or make a suicide contract with the patient, sleepless nights and constant worry are significant hazards of the profession. 8. Grief Cycle: The endless cycle of introductions to new patients, conducting psychotherapy, and finally terminating the relationship takes an additional toll on practitioners. Therapists need to connect and disconnect on a regular basis. In many cases they never hear from their patients after termination. When patients terminate abruptly, therapists are left to grieve without sufficient closure. 9. One-way Intimacy and Voyeuristic Attitudes: While many patients disclose the most intimate aspects of their lives to their therapists, the therapist must share only what is appropriate and beneficial to the patients. Experiencing many such relationships can lead the practitioner to acquire extreme voyeuristic tendencies. It may also lead therapists to transfer the mode of one-way intimacy to friends and lovers outside of the therapy office. 10. Distraction: Focusing on other people's problems, which may be more severe than their own, often leads therapists to lose track of their own situation. The sense of power and invulnerability that often characterizes care-givers may also contribute to practitioners' lack of attention to their own problems. 11. Inability to Shut off the Therapeutic Stance: After being an expert and helper for many hours, some therapists find it hard to leave the therapeutic or analytic stance behind. Interaction with friends, family members, and lovers in a mutual way without jargon or a feeling of expertise and where power is equally shared, can be beyond the scope of the therapist. 12. Events that Affect Effectiveness: Therapists, like most people, go through life events, such as death of a parent, severe illness in the family, divorce, mid-life crisis, and accidents. Because the most important tool therapists bring to their offices is themselves, events that happen in the course of their lives affect not only them, but also their ability to be effective and productive with their patients. 13. Conflicting Clinical, Ethical, and Legal Considerations: The rapidly growing number of state laws, combined with the continual updating of ethical guidelines, leave clinicians in a quandary. The question of how to act when conflicting mandates are present (for example whether to act in the best interest of the patient, to follow the ethical guidelines, or obey the laws) may be difficult to decide. Regardless of the final decision, therapists are bound to feel stressed, compromised, and frustrated. 14. The Threat of Lawsuits: Living in a highly litigious society and working with disturbed people in the unwitnessed privacy of our offices leave therapists extremely vulnerable to lawsuits. As most situations boil down to a patient's word against a therapist's, the only proof of what therapists did (or did not do) is their notes. The only shield against litigation is clinical competency, a shield that can be easily shattered by shrewd attorneys and "hired guns," as there is very little scientific data to qualify any specific intervention as standard and effective conduct. 15. Split Personality-Public vs. Private: Traditional therapy emphasizes a rigid separation of the therapist's professional and personal life. With some types of people this differentiation is crucial for therapeutic and safety reasons. However, the preoccupation with such separation has led therapists to live isolated and limited lives and to exclude a sizable part of their community and their public lives from their experience. B. HAZARDS TO THE THERAPIST'S FAMILY 1. Emotional Drain: Listening all day to people in pain depletes the therapist. At the end of the day the skillful listener may be exhausted. Home problems seem minor, dull, and insignificant compared to the horrendous stories patients have shared. Many therapists prefer to be left alone at home, while others see homecoming as their first opportunity of the day to unburden themselves and stop the flow of other people's complaints. 2. Interpretation: The psychotherapist's most pervasive intrusion on the psychic lives of their family members is interpretation. Interpretation of dreams, slips of the tongue, or unconscious behavior, whether correct or incorrect, is harmful. Interpretations foster distrust, foment a sense of exposure, and may create excessive self-consciousness in those being interpreted. 3. Questioning and Inquiry: Psychotherapists are trained to ask questions or to reflect back in a way that facilitates better understanding. Many children and spouses respond poorly to continuing questioning, such as "Why do you feel that?" or "Did you consider the consequences?" Lengthy interrogations (which may last 50 minutes and during which the therapist-parent is totally rational and composed) confuse kids, who appropriately expect their parents to sometimes lose their professional composure, become more engaged, and display a normal range of human behavior rather than use the interpretive "Freudian whip." 4. Distancing and Use of Jargon: Another common complaint among the psychotherapist's family members is their parent's or spouse's ability to distance themselves from the emotional realities of the domestic scene. This dispassionate aura, while an important therapeutic mode for some clinicians, is also characteristic of many therapists' intimate interactions. The use of jargon as a means of distancing is usually used as a counter attack when the therapist feels defensive or uninvolved. Often the therapist lashes out with, "you are projecting," meaning, "your anger has nothing to do with me." 5. Total and Uncritical Understanding: Children of psychotherapists often say that whatever they did, their parents always accepted and understood it. In the psychotherapist's words, they were "just going through a phase." Different versions of this theme are expressed in statements like "Oh, he's such a pre-teen," or "How typically adolescent," or "It is just your middle age crisis." These demeaning and discounting comments hurt loved ones even if accurate. The "total understanding" syndrome often manifests to the extent that therapists will excuse all behavior. In their mind the bully is insecure, the wimp has abusive parents, and the thief comes from a poor family. It may be difficult for children to share their frustrations and anger in the light of their therapist-parent's infinite ability to "understand." 6. Labeling and Diagnosing: These therapeutic techniques pose similar problems to those of interpretation and total understanding. Children and partners of therapists are labeled narcissistic, passive-aggressive, borderline, and many other DSM III-R diagnostic categories by their therapist-parents or spouses. Labeling is extremely injurious. Calling children "hyperactive" or "accident prone" is likely to encourage hyperactivity and accidents. Children learn who they are largely from their parents. If they are called offensive names, too often they will internalize and incorporate these labels as part of their identity. 7. Anonymity and Confidentiality in Family Life: The commitment to keep patients' identities anonymous prevents many therapists from sharing their professional lives with the rest of the family. This results in a wide gap between therapists and their families, as the rest of the family is neither aware of nor included in the therapists' professional struggles, pains, wonders, and joys. 8. The Public and Personal Split: The need of many therapists to keep their personal lives completely concealed from their patients often places psychotherapists and their families in difficult, stressful, and awkward situations. Many therapists avoid going to certain parties or joining health clubs, determined not be seen by their patients out of the office. This rigid split isolates and alienates not only the therapists, but their families as well. 9. Jealousy: Family members also may experience jealousy of the psychotherapist's patients. Clients who are anonymous and mysterious to the family have uninterrupted weekly time with the parent/spouse, share their most intimate secrets, and call the therapist at all hours of the day or night. Regardless of how demanding or disturbed they are, these clients are fully accepted by the therapist-parents. Many therapists' children and spouses feel neglected and deprived. Some therapists' children report that they want to grow up to be patients. 10. Responding only to Crisis: One of the most successful means of getting a psychotherapist's attention is to create a crisis situation. Psychotherapists are usually at their best in an emergency in which people are clearly in need of support. This skill is easily transferable from the therapy room to the home. After hours of listening to bizarre and dramatic stories, many psychotherapists are not eager to be ardent listeners to complaints about homework assignments or the car's funny noise. Physical illness, accidents, and other crises often provide, albeit dangerously, the attention that children or spouses of psychotherapists are missing. 11. The Home Office: Working out of the home office adds another dimension to the psychotherapist's already complex family dynamics. The home office can offer advantageous possibilities for therapists and patients. However, it becomes a liability if therapists enforce a rigid separation between patients and family members, and especially if this restricts children's freedom and spontaneity. Children whose parents work out of a home office seem to be much more resentful of their parents' profession due to the added limitations on space, time, noise levels, and general playfulness imposed by the home-office arrangement. 12. Resistance in Therapy: When the family dynamic has deteriorated to the point where outside help is sought, the therapist-spouse/parent may further complicate matters by creating obstacles to the healing process. Resistance to family therapy or marriage counseling is often an attempt to avoid negative exposure. It manifests through initial denial of the problem. Once in therapy there is reluctance to cooperate with the hired therapist. Competition, shame, or becoming a co-therapist are common ways to interfere with therapy. Many patient-therapists use sophisticated jargon during family therapy sessions, clearly an attempt to ally with the hired therapist. These un-constructive gestures support the original mistrust the therapist has evoked in the other family members. 13. Demeaning Tales: Sharing stories and tales about patients at the dinner table is a common activity in psychotherapists' homes. When the stories are not respectful of the patients or when ridicule is prevalent the potential of adverse effects on other family members, especially children, is great. Demeaning stories are not only a reflection of a failed alliance between therapist and patient, but also an alarming warning to the children about their parents' ability to demean others-including their own children. 14. Treating Family Members as Patients: The line between being an involved and loving spouse or parent and a therapist is often very thin. It should be walked very carefully. The danger of treating family members as patients is an over-arching concern and often the context for the many hazards mentioned above. If the therapist-parent takes on the role of therapist in the home, the spouse or child will most likely assume the role of patient and lean towards self-defeating and self-destructive behavior and attitudes. C. ON BURNOUT Burnout is a result of job stress stemming from the numerous hazards of the profession described in the preceding sections. At different periods of their careers, it affects all psychotherapists to some degree. Unlike the commonly held belief that burnout is experienced primarily by seasoned therapists, research has shown its frequent occurrence with neophyte therapists as well. Maslach, who wrote the important book Burnout - The Cost of Caring, states "It is a response to the chronic emotional strain of dealing extensively with other human beings, particularly when they are troubled or having problems." Burnout manifests primarily as the therapists' emotional exhaustion and depersonalization of both their patients and themselves. It has also been called "emotional fatigue" or "emotional overload," when the therapist feels drained, depleted, all used up, with nothing else to give out. The depersonalization aspect of burnout manifests through general dislike of, and a detached and callous even dehumanized attitude towards the people served. The burned-out therapist experiences low energy, reduced interest and satisfaction, and often dreads work. Burnout in beginning therapists is linked closely to emotional overload and a sense of inefficacy. Burnout is the leading cause of psychotherapists' high rate of depression, drug and alcohol abuse, and suicide. Due to the myth of care-giver invulnerability, psychotherapists are susceptible to burnout. Research has shown that psychotherapists are more prone to becoming depressed, substance abusing, or suicidal than any other comparable profession, such as physicians, attorneys, accountants, and dentists. D. HOW TO PREVENT BURNOUT Burnout is preventable. Attending to the above hazards of the profession and following the guidelines below can help psychotherapists minimize the dangers of the profession, avoid burnout, increase job satisfaction, and provide better quality services to their patients. Preventing burnout - The professional front: 1. Be involved in your own therapy: As we are the main tool of our trade, we need to stay sharp, sensitive, in-tune, and responsive. 2. Use consultations and supervisions regularly: Frequently and inevitably we encounter difficult cases for which we must obtain some help, advice, and/or facilitation. 3. Use an interdisciplinary approach: Using one approach or theoretical orientation is not sufficient. Different clients have different needs and require a variety of accessible approaches. Successful therapists not only draw from different psychological theories, they also draw from other disciplines such as philosophy, religion, anthropology, mythology, and sociology. 4. Belong to a professional organization: As part of the membership, you will receive their monthly publication. The importance of such membership is in its inherent support as well as the continuous updating of professional and political developments relevant to private practice. 5. Practice risk management: Continuing to update yourself on changing laws and ethical guidelines is a crucial part of risk management. In addition, keep excellent records and avoid dual relationships. This will reduce the likelihood of lawsuits and disciplinary actions and, additionally, help to alleviate anxiety and worry. 6. Practice sound private practice management: Be sure that all your office policies, consent to treatment, and release of information forms are signed. Take good clinical notes and keep good records. Bill regularly and document all important clinical, legal, ethical, and managerial decisions. Update the treatment plan regularly. 7. Continuing education: Make an ongoing commitment to invest in broadening your professional horizons. Take courses regularly on the theoretical, clinical, and managerial aspects of private practice. 8. Warn your family members and friends about the hazards of the profession: People who are close to us can often detect burnout symptoms even before we notice them. Preventing burnout - The personal front: 9. Be involved in non-professional activities: Develop interests and hobbies that are not related to psychology, such as opera, hiking, baseball, stamps, etc. 10. Be involved in your community: An important way to break the isolation of private practice is to be involved in your own community with schools, local community activities, Little League, educational board, local theater, recycling center, etc. 11. Take time off from your practice or go on vacation: Private practice does not have paid vacations. Each time we go away, we lose income while paying out for vacation expenses. Nevertheless, in order to avoid burnout and practice effectively we need regular time off. Professional conferences, even in exotic cities, are not to be counted as vacations. They are hard work. 12. Attempt to diversify your friendships: Try to broaden your social contacts beyond psychotherapists and their families. It helps with developing better perspectives and appropriate distance from what we do daily. 13. Separate the therapeutic mode from the familial: While much therapeutic knowledge and experience is relevant to our familial lives, we must operate differently in these two milieus. In the home there is no hierarchy or single expert as there is in the office. While therapy is limited by money and time, the family does not have such contracts. The therapist must be rational and methodical in practice but should display a much broader range of feelings, thoughts, and behavior at home. It is important to know how to turn off the therapeutic/analytic mode. Mutuality and vulnerability are the pillars of intimate relationships but not necessarily a good basis for solid therapy. While the focus of therapy is maladjusted behavior, hopefully, it is not the focus of the therapist's private life. Preventing burnout - The art of balancing: 14. 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