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ebook
THE GUILFORD PRESS
LEAVING IT AT THE OFFICE
LEAVING IT
at the OFFICE
A Guide to
Psychotherapist Self-Care
SECOND EDITION
John C. Norcross
Gary R. VandenBos
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that are
accepted at the time of publication. However, in view of the possibility of human error or
changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor
and publisher, nor any other party who has been involved in the preparation or publication of
this work warrants that the information contained herein is in every respect accurate or com-
plete, and they are not responsible for any errors or omissions or the results obtained from
the use of such information. Readers are encouraged to confirm the information contained
in this book with other sources.
vi
Preface
is one locale for improving our craft. We envision this volume serving, second
of all, as a supplemental text in psychotherapy and counseling courses. The
book will fit easily into practice, ethics, and professional preparation courses.
Like-minded professors may assign our text as part of a graduate seminar on the
person of the therapist as well.
This edition brings a host of updates and improvements that reflect trends in
the field and in personnel. Among the most prominent of these:
In the late 1950s Holt and Luborsky (1958) compiled expert opinions on the
personal qualities sought in successful applicants for psychotherapy training.
Their three criteria pertain equally, it seems to us, to a good book about psy-
chotherapy.
First on the list is an introspective orientation: observing the inner life, com-
mitting to self-observation, engaging in appropriate self-disclosure. Introspec-
tion obviously guides and drives our work. Similarly, we propose that you pro-
actively encounter this book rather than reactively respond to it.
You might pose to yourself questions raised in the following 13 chapters.
For instance: Do I fully recognize the hazards of my work? How often do I
receive (or seek) nurturing relationships to offset the emotional toll of this
Preface ix
Form should parallel content. The content of this book concerns the
intimate experiences of the psychotherapist; the writing too should be
personal. A detached, objective view of the intimate, subjective life of
the psychotherapist strikes us as incongruent.
Be data-based. This world of ours lacks many qualities, but notably
these: data and humor. We value the insights of the great masters;
however, we place empirical data and narrative truth above traditional
authority. Freud was certainly mistaken at times (and some would argue
frequently), but it is not the duty of the pioneer to say the last word.
Rather, the pioneer says the first word, and our task is to follow his line
of inquiry faithfully by the host of clinical and research methods at our
disposal (Guntrip, 1971).
Preface xi
participating in healthy escapes, renewing your spirituality, so that you are fully
charged for the onslaught of intense contact with distressed and disturbing
clients.
The upshot of these paradoxes is that a balanced and comprehensive plan
for your self-care as a mental health professional will require a dual focus: in
your workplace and outside your workplace. Accordingly, Chapters 2 through
13 are divided into sections labeled “At the Office” and “Away from the Office.”
Patients frequently act, for defensive purposes, as though psychotherapists do
not have lives outside the consulting room. We shall not commit the same
error.
Consistent with our relativistic perspective, we present more than one way to
promote self-care. Life is not a uniform game with identical rules for all. Nor
can problems be solved by mindlessly following a prescribed set of universal
instructions. In Zen and the Art of Motorcycle Maintenance, Robert Pirsig (1974)
put it this way:
What’s really angering about instructions of this sort is that they imply
there’s only one way to put this rotisserie together—their way. And that
presumption wipes out all creativity. Actually there are hundreds of ways
to put the rotisserie together and when they make you follow just one
way without showing you the overall problem the instructions become
hard to follow in such a way as not to make mistakes.
We are grateful to the many psychotherapists who, over the years, have par-
ticipated in our research studies, attended our workshops, entered psychological
treatment with us, and frequented our convention presentations. Their insights
and experiences have shaped the recommendations found in this book.
Thirty-two master psychotherapists deserve special acknowledgment for
participating in individual interviews with us on the ways they alleviate the
distress of conducting psychotherapy. We have interspersed their experiences
and wisdom throughout the book:
xv
xvi Acknowledgments
5 Nurturing Relationships 77
6 Setting Boundaries 99
References 236
Index 265
xvii
LEAVING IT AT THE OFFICE
1
Valuing the Person
of the Psychotherapist
There is only one recipe—to care a great deal for the cookery.
—Henry James
experienced change agents. Yet, compared with the tens of thousands of stud-
ies on how our patients change, we know relatively little (at least publicly)
about how we cope with our own distress or change our own behavior or
struggle with the hazards of our craft. The tendency to view psychotherapists
as not having lives outside the consulting room apparently afflicts us as well
as our clients.
This book—and psychotherapist self-care—starts with valuing the person
of the psychotherapist.
CONFLUENCE OF INDIVIDUAL
AND ENVIRONMENT
A leitmotif of this book is the interdependence of the person and the envi-
ronment in determining effective self-care. The self-care and burnout fields
have been polarized into rival camps. One camp focuses on the individu-
al’s deficits—the “fault, dear Brutus, is in ourselves” advocates—and cor-
respondingly recommends individualistic solutions to self-care. The other
camp emphasizes systemic and organizational pressures—the “impossible
profession with inhumane demands” advocates—and naturally recommends
environmental and social solutions. In this book, we value both camps and
adopt an interactional perspective that recognizes the reciprocal confluence
of person-in-the-environment. The self is always in a system.
When conceptualizing the self-in-a-system, we repeatedly point to the
unique motives, family of origins, and underlying psychodynamics of mental
health professionals. What drives a person to concern herself with the dark
side of the human psyche? What is it that compels certain people to elect to
help those who are suffering, wounded, or dysfunctional? Assuredly they are a
“special sort,” since the average person prefers to downplay the psychic suffer-
ings of fellow humans and avoid extensive contact with troubled individuals
(Norcross & Guy, 1989).
The question of motivation—why did I (really) become a psychothera-
pist?—is obviously not a simple or entirely conscious one. To be sure, altru-
ism “to help people” and idealism “for a better world” constitute two cor-
nerstones of the vocational choice, but it is incomplete. It begs the deeper,
selfism questions: Why is “helping people” of utmost concern for you? What
makes it a deeply satisfying experience? Of all the helping careers—assisting
the homeless, saving the environment, rendering public service, teaching the
uneducated, tending to physical ills—why this career as a psychotherapist?
Even the most saintly among us is moved by a complex stew of motives, some
admirable and some less so, some conscious and some less so. Psychothera-
pists frequently report that they come to realize the reasons they chose their
discipline only well into their careers or during the course of intensive per-
sonal therapy (Holt & Luborsky, 1958).
The failure to consider the individual motives, needs, and vulnerabilities
of psychotherapists renders much of the well-intended practical advice on self-
care hollow and general. To paraphrase Freud, it’s akin to giving a starving
Valuing the Person of the Psychotherapist 5
As we write this chapter, we are painfully aware that our message runs counter
to the zeitgeist of the industrialization of mental health care. Managed care
devalues the individuality of the practitioner, preferring instead to speak of
“providers delivering interventions for ICD or DSM diagnoses.” The pervasive
medical model prefers manualized treatments for discrete disorders over heal-
ing relationships with unique humans. The evidence-based practice movement
highlights research evidence in favor of specific treatments and downplays the
evidence for the curative powers of the human clinician (and patient). Our
emphasis on valuing the person of the therapist may seem a nostalgic throw-
back to the 1970s and 1980s.
At the same time, we detect a dawning recognition, really a reawakening,
that the therapist herself is the focal process of change. “The inescapable fact
of the matter is that the therapist is a person, however much he may strive to
make himself an instrument of his patient’s treatment” (Orlinsky & Howard,
1977, p. 567). This book stands firmly against the encroaching tide of the tyr-
anny of technique and the myth of disembodied treatment.
The pursuit of technical competency has much to recommend it, but it may
inadvertently subordinate the value of the personal formation and maturation of
the psychologist (Norcross, 2005b). The ongoing march toward evidence-based
practices tends to neglect the human dimensions of the practitioner, patient,
and psychotherapy (Norcross et al., 2017). It has created an environment where,
as Thoreau complains in Walden (1854, p. 25), “men have become the tools of
their tools.” Movements that address only, or primarily, the techniques of psy-
chotherapy quickly become arid, disembodied, and technical enterprises.
Lest we be misunderstood on this point, let us reveal our bias, a bias rooted
in years of conducting psychotherapy and research. Effective practice in men-
tal health must embrace the treatment method, the individual therapist, the
therapy relationship, the patient, and their optimal combinations (Norcross &
Lambert, 2005). We value the power of the individual therapist, but not only
that. As integrative therapists, we avoid the ubiquitous pull toward dichoto-
mous and polarizing characterizations of the evidence. The evidence tells us
that successful psychotherapy is a product of many components, all of which
revolve around, and depend upon, the individual psychotherapist. That’s good
science and good relationships.
6 LEAVING IT AT THE OFFICE
For those not convinced or only partially convinced by the scientific evidence
on the person of the psychotherapist, we now turn to self-care’s ethical impera-
tive. Every ethical code of mental health professionals includes a provision or
two about the need for self-care. The American Psychological Association’s
Ethical Principles and Code of Conduct (2010), for example, directs psycholo-
gists to maintain an awareness “of the possible effect of their own physical and
mental health on their ability to help those with whom they work.” One section
(2.06) of the code instructs psychologists, when they become aware of personal
problems that may interfere with performing work-related duties adequately,
to “take appropriate measures, such as obtaining professional consultation or
assistance, and determine whether they should limit, suspend, or terminate
their work-related duties.”
Similarly, the National Association of Social Work Code of Ethics (2008)
advises practitioners to monitor their performance, warns against practicing
while impaired, and recommends “remedial action by seeking professional help,
making adjustments in workload, terminating practice, or taking any other
steps necessary to protect clients and others.” The American Counseling Asso-
ciation’s (2014) Code of Ethics, for another example, goes further in proactively
instructing counselors to “engage in self-care activities to maintain and pro-
mote their own emotional, physical, mental, and spiritual well-being to best
meet their professional responsibilities.” No wonder that multiple organizations
have joined the National Academy of Practice (2016) to launch an Action Col-
laborative on clinician well-being and resilience.
Without attending to our own care, we will not be able to help others and
prevent harm to them. Psychotherapist self-care is a critical prerequisite for
patient care. In other words, self-care is not only a personal matter but also an
ethical necessity, a moral imperative (Barnett et al., 2006; Wise et al., 2012).
Not an indulgence, not an option, but a professional responsibility. We gently
urge you to challenge the morality of self-sacrifice at all costs and to embrace
the indispensability of self-care.
Ethically speaking, you care best for your clients when you take sufficient
care of yourself. The message is that simple yet that profound and demanding.
don’t you take a break for a few minutes and sharpen that saw? I’m sure it
would go a lot faster.” The man emphatically replies: “I don’t have time
to sharpen the saw. I’m too busy sawing!”
That is the first paradox of self-care: no time to sharpen the saw! The
story, incidentally, comes from Stephen Covey’s (1989, p. 287) The 7 Habits of
Highly Effective People. It is sooo easy to see and diagnose it in other people; it is
sooo hard to get off the treadmill ourselves.
The existential–humanistic therapists Sapienza and Bugental (2000,
p. 459) put the self-care paradox bluntly: “Many of us have never really learned
how to take the time to care and to nourish ourselves, having been trained to
believe that this would be selfish. . . . Nor have most psychologists taken the
time to develop compassion for themselves, and compassion for their wounds.”
Not that psychotherapists are opposed to self-care; far from it. Instead, we
are busy, multitasking professionals dedicated to helping others but who fre-
quently cannot locate the time to help ourselves. Clients, families, paperwork,
colleagues, students, and friends seem to always assume priority. The ideal bal-
ance of caring for others and for ourselves tends to favor the former. At the risk
of redundancy, we believe it begins with prioritizing the value of yourself as a
person/psychotherapist.
The point segues into another paradox of psychotherapist self-care: Not
availing ourselves of what we provide or recommend to clients. We often feel
hypocritical or duplicitous—suggesting to others that they work less, exercise
more, renew themselves, and so forth—while we do not take our own advice.
How often do we sit with patients, encouraging them to “relax and take a vaca-
tion,” while calculating in our own case our lost therapy revenue and airfare
and concluding that we can’t afford to take the time away from the office right
now (Penzer, 1984)?
A representative example from one of our workshop participants is instruc-
tive:
Bien des heures après que Kazan fût tombé sur la rive du fleuve,
sous le coup de fusil de Sandy Mac Trigger, Louve Grise attendit
que son fidèle compagnon vînt la retrouver. Tant de fois il était
revenu vers elle qu’elle avait confiance dans son retour. Aplatie sur
son ventre, elle reniflait l’air et gémissait de n’y point découvrir
l’odeur de l’absent. Mais, de tout le jour, Kazan ne reparut point.
Le jour et la nuit étaient depuis longtemps semblables pour la
louve aveugle. Elle sentait pourtant, par un secret instinct, l’heure où
les ombres s’épaississaient, et que la lune et les étoiles devaient
briller sur sa tête. Mais, avec Kazan à côté d’elle, l’effroi de sa cécité
n’était plus pareil. Le même abîme des ténèbres ne lui semblait pas
l’envelopper.
Vainement elle lança son appel. Seule lui parvint l’âcre odeur de
la fumée qui s’élevait du feu allumé par Mac Trigger sur le sable. Elle
comprit que c’était cette fumée, et l’homme qui la produisait, qui
étaient la cause de l’absence de Kazan. Mais elle n’osa pas
approcher trop près ses pas ouatés et silencieux. Elle savait être
patiente et songea que, le lendemain, son compagnon reviendrait.
Elle se coucha sous un buisson et s’endormit.
La tiédeur des rayons du soleil lui apprit que l’aube s’était levée.
Elle se remit sur ses pattes et, l’inquiétude l’emportant sur la
prudence, elle se dirigea vers le fleuve. L’odeur de la fumée avait
disparu ainsi que celle de l’homme, mais elle percevait le bruit du
courant, qui la guidait.
Le hasard la fit retomber sur la piste que, la veille, Kazan et elle
avaient tracée, lorsqu’ils étaient venus boire sur la bande de sable.
Elle la suivit et arriva sans peine à la berge, à l’endroit même où
Kazan était tombé et où Mac Trigger avait campé.
Là son museau rencontra le sang coagulé du chien-loup, mêlé à
l’odeur que l’homme avait, tout à côté, laissée sur le sable. Elle
trouva le tronc d’arbre auquel son compagnon avait été attaché, les
cendres éteintes du foyer, et suivit jusqu’à l’eau la traînée laissée par
le corps de Kazan, lorsque Mac Trigger l’avait tiré demi-mort,
derrière lui, vers la pirogue. Puis toute piste disparaissait.
Alors Louve Grise s’assit sur son derrière, tourna vers le ciel sa
face aveugle et jeta vers Kazan disparu un cri désespéré, tel un
sanglot que le vent emporta sur ses ailes. Puis, remontant la berge
jusqu’au plus prochain buisson, elle s’y coucha, le nez tourné vers le
fleuve.
Elle avait connu la cécité, et maintenant elle connaissait la
solitude, qui venait y ajouter une pire détresse. Que pourrait-elle
faire ici-bas, désormais, sans la protection de Kazan ?
Elle entendit, à quelques yards d’elle, le gloussement d’une
perdrix des sapins. Il lui sembla que ce bruit lui arrivait d’un autre
monde. Une souris des bois lui passa entre les pattes de devant.
Elle tenta de lui donner un coup de dent. Mais ses dents se
refermèrent sur un caillou.
Une véritable terreur s’empara d’elle. Ses épaules se
contractaient et elle tremblait, comme s’il avait fait un gel intense.
Épouvantée de la nuit sinistre qui l’étreignait, elle passait ses griffes
sur ses yeux clos, comme pour les ouvrir à la lumière.
Pendant l’après-midi, elle alla errer dans le bois. Mais elle eut
peur et ne tarda pas à revenir sur la grève du fleuve, et se blottit
contre le tronc d’arbre près duquel Kazan enchaîné avait dormi sa
dernière nuit. L’odeur de son compagnon était là plus forte
qu’ailleurs et, là encore, le sol était souillé de son sang.
Pour la seconde fois, l’aube se leva sur la cécité solitaire de
Louve Grise. Comme elle avait soif, elle descendit jusqu’à l’eau et y
but. Quoiqu’elle fût à jeun depuis deux jours, elle ne songeait point à
manger.
Elle ne pouvait voir que le ciel était noir et que dans le chaos de
ses nuages sommeillait un orage. Mais elle éprouvait la lourdeur de
l’air, l’influence irritante de l’électricité, dont l’atmosphère était
chargée, et qui s’y déchargeait en zigzags d’éclairs.
Puis l’épais drap mortuaire s’étendit, du sud et de l’ouest, jusqu’à
l’extrême horizon, le tonnerre roula et la louve se tassa davantage
contre son tronc d’arbre.
Plusieurs heures durant, l’orage se déchaîna au-dessus d’elle,
dans le craquement de la foudre, et accompagné d’un déluge de
pluie. Lorsqu’il se fut enfin apaisé, Louve Grise se secoua et, sa
pensée toujours fixée vers Kazan qui était bien loin déjà à cette
heure, elle recommença à flairer le sable. Mais l’orage avait tout
lavé, le sang de Kazan et son odeur. Aucune trace, aucun souvenir
ne restaient plus de lui.
L’épouvante de Louve Grise s’en accrut encore et, comble de
misère, elle commença à sentir la faim qui lui tenaillait l’estomac.
Elle se décida à s’écarter du fleuve et à battre le bois à nouveau.
A plusieurs reprises, elle flaira divers gibiers qui, chaque fois, lui
échappèrent. Même un mulot dans son trou, qu’elle déterra des
griffes, lui fila sous le museau.
De plus en plus affamée, elle songea au dernier repas qu’elle
avait fait avec Kazan. Il avait été constitué par un gros lapin, dont
elle se souvint qu’ils n’avaient mangé que la moitié. C’était à un ou
deux milles.
Mais l’acuité de son flair et ce sens intérieur de l’orientation, si
puissamment développé chez les bêtes sauvages, la ramenèrent à
cette même place, à travers arbres, rochers et broussailles, aussi
droit qu’un pigeon retourne à son colombier.
Un renard blanc l’avait précédée. A l’endroit où Kazan et elle
avaient caché le lapin, elle ne retrouva que quelques bouts de peau
et quelques poils. Ce que le renard avait laissé, les oiseaux-des-
élans et les geais des buissons l’avaient à leur tour emporté. Le
ventre vide, Louve Grise s’en revint vers le fleuve, comme vers un
aimant dont elle ne pouvait se détacher.
La nuit suivante, elle dormit encore là où avait dormi Kazan et,
par trois fois, elle l’appela sans obtenir de réponse. Une rosée
épaisse tomba, qui aurait achevé d’effacer la dernière odeur du
disparu, si l’orage en avait laissé quelques traces. Et pourtant, trois
jours encore, Louve Grise s’obstina à demeurer à cette même place.
Le quatrième jour, sa faim était telle qu’elle dut, pour l’apaiser,
grignoter l’écorce tendre des saules. Puis, comme elle était à boire
dans le fleuve, elle toucha du nez, sur le sable de la berge, un de
ces gros mollusques que l’on rencontre dans les fleuves du
Northland et dont la coquille à la forme d’un peigne de femme ; d’où
leur nom.
Elle l’amena sur la rive avec ses pattes et, comme la coquille
s’était refermée, elle l’écrasa entre ses dents. La chair qui s’y
trouvait enclose était exquise et elle se mit en quête d’autres
« peignes ». Elle en trouva suffisamment pour rassasier sa faim. En
sorte qu’elle demeura là durant trois autres jours.
Puis, une nuit, un appel soudain sonna dans l’air, qui l’agita d’une
émotion étrange. Elle se leva et, en proie à un tremblement de tous
ses membres, elle trottina de long en large sur le sable, tantôt
faisant face au nord, et tantôt au sud, puis à l’est et à l’ouest. La tête
rejetée en l’air, elle aspirait et écoutait, comme si elle cherchait à
préciser de quel point de l’horizon arrivait l’appel mystérieux.
Cet appel venait de loin, de bien loin, par-dessus le Wilderness. Il
venait du Sun Rock, où elle avait si longtemps gîté avec Kazan, du
Sun Rock où elle avait perdu la vue et où les ténèbres qui
l’enveloppaient maintenant avaient, pour la première fois, pesé sur
ses paupières. C’est vers cet endroit lointain, où elle avait fini de voir
la lumière et la vie, où le soleil avait cessé de lui apparaître dans le
ciel bleu, et les étoiles et la lune dans la nuit pure, que, dans sa
détresse et son désespoir, elle reportait tout à coup sa pensée. Là,
sûrement, s’imaginait-elle, devait être Kazan. Alors, affrontant sa
cécité et la faim, et tous les obstacles qui se dressaient devant elle,
tous les dangers qui la menaçaient, elle partit, abandonnant le
fleuve. A deux cents milles de distance était le Sun Rock, et ç’était
vers lui qu’elle allait.
XXVIII
COMMENT SANDY MAC TRIGGER
TROUVA LA FIN QU’IL MÉRITAIT