 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind Close Doors podcast, with Bob Cook and Jackie Jones. Welcome back to the next episode of The Therapy Show, behind Close Doors. This is episode 49, Bob. Oh, God. I know. We're flying through them. And this episode is all around compassion fatigue in therapy, although you have just said this happens anywhere. Well, yes, in lots of different places, but we'll start off looking at the process in therapy. Yes. It's a big thing, compassion fatigue. Yeah. Yeah. How do you see the compassion fatigue that in your practice or from where you're standing? What do you think about it? I think in the early days, when I first qualified and was first seeing clients, I think I probably over-identified a lot more than what I do now, maybe. Yeah. I can remember. I think I might have had this conversation with the supervisor and saying it was like I had a bit of a radar on the top of my head and it just sucked everything in. And I was told that over time, that would not happen. And I think that's true. Oh, so you're sort of likening this to sort of what I would call a compulsive care-taking position. Yeah. Well, that's me. I was a childminder. I've always worked with kids. I'm an ex-foster carer. I'm now a psychotherapist, so it's kind of in my DNA. Not being a compulsive care-taker. Yeah. So compassion fatigue is something to really look at for with you then. Definitely. And I definitely felt it in the early days, more so than what I do now. But having said that, sometimes the universe brings us clients that are kind of going through similar things than what we are. So how did it manifest for you then in those days? I found it hard to shake off the clients once the session had finished. And that was one of my big concerns when I started seeing clients at home. I had this sort of fantasy that it would taint my house, if that made sense. What would taint you? Say a little bit more about that. Just the feelings of therapy, basically, or being a therapist. Like I said, I used to struggle shaking a client off. We had quite an in-depth session. It would take me a while to come down from it. So you would sort of take the feelings on maybe like in a litmus paper Yeah. Whereas when I was working from MIP, I had the drive home. So I would kind of, you know, I don't know, just talk myself down on the 45-minute drive back home. Whereas when I was seeing clients in my home, I did have a fear that it would stay there for a bit longer. I think that's a good way to describe it. I think when you talk about compassion fatigue, we're often talking about a transferential position where we over-identify. I think that's what you're talking about. That's why one of the signs of that would be to maybe constantly think about your client when you go home or even dream about your client. And you know, it's a good phrase, what you said, I think, have difficulty shaking off the thought, the images, the desires, or whatever the transference is with your clients. And worrying about them in between sessions. That was another thing that I used to do a lot of. Yeah. See, the way to get through this is supervision, supervision, therapy, therapy. Yeah, 100%. So if you have your take care of yourself, yourself, have therapy, have supervision, then you can lessen the effects of so-called compassion fatigue. Yeah. But you have to take care of yourself professionally at that level, I think. Definitely. Particularly. And peer groups and colleagues and things like that. Yeah. I think for me, it was about learning and understanding, you know, particularly through the assessment process and everything, that the client, you know, was okay at taking care of themselves as well. He wasn't my job to take care of them in between sessions. That was a big thing that I needed to learn to do. Yeah. The clients, when you say, okay, I do know what you mean, that they have a responsibility themselves to be. Yeah. And enough adult capacity to take care of themselves. Yeah. Well, some, I sort of hesitated because for some clients, of course, they're so badly damaged that their self-care process is limited. Yeah. Yeah. So it's yes and no really. I understand why you're coming from terms of compassion fatigue, but you know, some clients are so damaged that they don't know how to take care of themselves. Yeah. I think the big thing is, it's not your responsibility to take ownership of that position. Yeah. Because as well, I don't know if you feel about it, but I did kind of have a bit of an insight or a realisation at some point that if I take on the hurt and their feelings, it's kind of disempowering them because it's not my trauma. It's not my stuff. Oh, certainly, isn't it? Yeah. Yeah. Trauma, that's for damn sure. Yeah. But sometimes, and with some clients in the early days, it felt like that. It felt like it was your trauma. Yeah. Like I said, it took me a while to shake it off. There was definitely physiological stuff going on for me after the session. So then therapy and supervision are crucial. Yeah. Yeah. I mean, it's interesting for a lot of counsellors, they don't have that recommendation requirement that you have therapy. I know. And I think this is a perfect example of how not taking care of yourself in understanding and reflecting and dealing with the positive identification that transference can lead to great challenges. Yeah. And it is a tough job being a psychotherapist sometimes because people only come to you when things are bad. They don't come and bouncing through the door and tell you all the good things that are going on in the life. No, they won't. No, no, no. That's absolutely true. So if you have four or five clients in a day, that's four or five hours of people talking about a lot of deep, sometimes negative things. You need to take care of yourself. And the problem comes when you don't have that therapeutic support or that supervision and you're attempting to deal with the transference or implications or the positive identification by yourself. Yeah. That's a very dangerous position. Dangerous is a strange word, but it's a very challenging position. Yes, yeah. And like you said, there's a lot of counsellors out there that it's not mandatory. It's not something that they need to do. And I don't know whether supervision is taught to them on their training and the value of it. I think supervision is, but I don't think, well, I know that the, in the counselling training, its maximum is about 20 hours therapy. Yeah. Yeah. I don't know because I only know doing it through the transactional analysis world, but like I think I've said it in this podcast before, I didn't think there was anything wrong with me until I started turning to be a psychotherapist. You know, and it is possible for us to get triggered when we're in the therapy room with a client if we've not worked through our own stuff. Yeah. Yeah, absolutely. And if you haven't worked through your own stuff, you're very open to what we're talking about here in terms of professional fatigue, compulsive care taking or compulsive, it's a psychological term, but anyway, compulsive rescuing, which it helps no one. No. No, I think, you know, that was what I was meaning earlier on when I said it, disempowers the client, you know, if we're constantly rescuing and giving them all the answers and trying to fix everybody. It's disempowering. I do believe that, you know, with support and educative psychotherapy and everything, the majority of us have the answers in us. We just don't know where they are. So you usually find, especially when students start their placements, so they start, you know, the beginning of their clinical life, if you like. Yeah. The sort of position you're talking about here or what we're talking about here often rears its head because the early, early, early therapist often comes from a position that they believe they have to do something. They have to rescue the client in some sort of way. Yeah. Often they come into this, often they come into therapy because they're attracted to that actually in the compulsive care taking place. They often come into therapy thinking they have to do something. And they sort of almost, and that means in a patronising way, but they find it hard to take on board that actually the doing bit is actually being rather than actionistic doing. And that is you, is a very common process we find with beginning therapists. Yeah. And it's something I went through. You know, I think that's one of the things why I'm always talking about MAPER and how good the training is because, you know, it's a four year course, but two years in, once you've passed your competencies, you're seeing clients, but you're still under the umbrella and the support for another two years. So you kind of, you know, it's not like you just suddenly been trained and released into the world. You've got two years of, you know, contact with yourself as the trainer of supervision as part of the course. You know, that's what I love. I don't think I'd be practicing now if I'd have done it any other way. No, I think it's really important to take care of yourself and have the opportunity to support, have the supervision and move away from a compulsive care taking place for yourself and what we're talking about here, but also for the clients, which you identified at the beginning of this podcast. Yeah. Yeah. And, you know, I love the way that you said that sometimes it's just being as opposed to doing. We don't need to do lots of things, which again, I suppose it's a comfort blanket when you're first qualified is that, you know, you have lots of things that you're kind of using, you know, strategies and forms to fill out and questionnaires and this and that just because it's uncomfortable to just be in the room and go with whatever comes up rather than having a plan. I think for a little therapist, beginning therapist per se, being is a real challenge. Yeah. Because actually they've come from a place often where they're high achievers in their professions or they've got lots of strokes from doing things and being, just being, it's very challenging for them. And that's the real art and often a lot of therapy is needed from that and a lot of supervision to sort of be able to be. Now that might sound strange to people listening. I don't know if it does or it doesn't, but if there's always been a concentration on doing something, a person will feel a void or very odd, you know, if they're not taking the space to attempt to solve things for people. Yeah. And there's something as well about if we're constantly doing things in the therapy room, often it can be really cognitive and they're in the thinking and a lot of the time as opposed to going into feeling where, you know, I've been, you know, I've had the honor of being on one of your therapy marathon weekends where yeah, to sit on a couch with somebody and say nothing is really powerful. It's a real challenge for a lot of people. Yeah, yeah. But if we're not doing things a lot of the time, we get out of our head and we go to a different place, which is what we, you know, is helpful in therapy. And I think that a lot of people question student therapists again, get so overwhelmed when they have to reflect on being as a major part of the therapy to process, but sometimes they learn that it's not for them. They've actually come into the place of being a therapist from such a compulsive caretaking position that is too overwhelming if they've then thrust into the challenge of looking at what being, you know, what being actually means for them. Yeah. Yeah. And, you know, I've seen clients that come with that as, you know, one of the barriers that they've got is that they need to be doing something all the time, you know, their anxiety or their overthinking or whatever it is happens when they've nothing to do. So to have a safe space in a room where they can explore that and be all clear with it is, you know, it's really useful. Absolutely. And so people can get really fatigued, that's why it's called compassion fatigue, for, from the script position often of feeling they always have to do things and show compulsive compassion all the time. And if they're not doing that, then something's wrong. Yeah. Yeah. And there is that over identification that we've already touched on, you know, I think it did take me a while to work out who's feelings or who's sometimes in the early days. You know, is this mine or is this theirs? It was, I don't know, the energy was just in the room and it was quite confusing as to who's it was at times, which sounds a bit woo-woo when you think about it. Well, yes and no, but you see, in life, I'm not talking about being a psychotherapist or a counselor on the mental health provisions, but you don't go around thinking, well, who's feelings of this? It's not part of your daily process in life. So, you know, therapists and counselors are entering a profession where that is a crucial question they need to ask themselves. Yeah. I'm glad it wasn't just me then. If they don't ask themselves that question and they take on all the trauma, the misery, the depression, the hurt that we're often dealing with in the therapeutic process, they will have great challenges and we could use the word fatigue, but they will they will have their finest job hard. I can remember as well. I'm not sure whether we've touched on it on any previous podcasts about, you know, the the clients that we take on as therapists and kind of like an 80-20 rule as to, you know, the type of clients that we take on, which is another way of, you know, making sure that we don't burn out as therapists. Yeah. So, explain for the listeners what 80-20 rule is. Well, you know, I know we've spoke about it in past, you know, sessions about the walking worried and things like that taking up 80% and the other 20% that maybe have more specific or deeper trauma and to be mindful of the clients that you're taking on so as, you know, you're avoiding that compassion fatigue. That's right. And I think it's another trap for beginning there, to take on many, many, many clients for various reasons. And certainly, if they're going to go and be put themselves in a position where client after client in the day, you know, is deeply scarred, deeply traumatized, et cetera, et cetera. And they believe we've got to cure or help the person heal themselves with a trauma every hour. They will certainly have fatigue very quickly. And be no use to themselves or text to the client. Yeah. So they need to take care of themselves. You know, I'm always interested when the beginning therapist particularly, but also very experienced therapist, you know, when you ask them, how many clients do you see in a day, for example? And they say, oh, 708. And, you know, that's a remarkable, remarkable response. Hmm. Oh, four in the morning, four in the afternoon. It's a remarkable response, especially if the therapist works in a lot with the disturbed population. Yeah. I did do that for a short period of time when I was working in Manchester and renting a room or hiring a room. Yeah. But I certainly don't do that now. And I realised quite early on that this is, this is not good. It's not good for me and it's not good for the clients either. Should be half that. Yeah. Yeah. Well, that's it. I work because I work from home. So I work, I kind of split it up into mornings, afternoons or, you know, daytime and then evenings. A lot of my clients are in the evening. So it's starting from five o'clock, you know, and I finish at nine o'clock. I'm usually seeing two or three tops, but generally just two in each section. People need to have, I think the prerequisite, and I'll keep repeating it and feel I'm labouring it, but therapy is so, so, so crucial. So you can differentiate out what's your own trauma and what's the other person's trauma or what's your feelings and what's the other person's feelings. And it doesn't get lumped up. And without that therapy or that person who's going to help you differentiate from your own script, if you like, in TA terms, your client script, fatigue will or challenges will happen. Yeah. I think, you know, it might be worth mentioning as well about, you know, if we're going through something. Yeah. Sorry, I'm just going to go again. Yeah, you're all right. Yes, you're right. You know, if we've been through a grief or, you know, something like that or going through a divorce or whatever it is that, you know, we need to be mindful of how we're going to be in that room and whether we're going to be serving our clients to the best of our ability if we're not taking care of ourselves. And it might be to take some time out. Well, now you're into a very, very important area. If you've got, you know, trauma in your own life, loss in your own life, bereavement in your own life, not only is happening in the here and now but maybe triggering off trauma from the past. Yeah. I think it's only ethical to take time out. Yeah. Me too. And if you don't, I think, okay, it might be a distraction for you, but it doesn't help the client. No, no, but I think it goes both ways. You see, I think the therapist can pass their own trauma on actually to the client. The client doesn't realise it. So they actually feel worse when they go out the door. Yeah. The therapist might feel better, but the client can feel down side worse because they're taking on the therapist, loss, grief, trauma. Yeah. And like you say, you know, it probably is unethical in one respect if you're not in the right frame of mind yourself with whatever's going on personally to be, you know, working with a client. Oh, it's definitely unethical. And I think the supervisor needs to point that out to the therapist pretty sharply because, as I say, it isn't, transference isn't just one way. Yeah. Yeah. You know, when people talk about the book, you know, read books about therapy and this and that, there's a lot of emphasis on, you know, the transferential position in terms of the client, but it's also the counter-transference of the therapist. Yeah. Definitely. So there's a lot in there then, well, basically, what would be your top three tips to avoid? To avoid. To avoid compassion fatigue. Taking too many clients on at once, especially the trauma laden ones. Yeah. To keep away from clients that may represent your own script in terms of trauma. Yep. In other words, don't step into the positive identification trap and move away from compulsive caretaking. And the way to do that is to start looking at your own challenges in therapy. Yeah. And supervision. Yeah. Yeah. Yeah. Supervision therapy at the top of the list. Yeah. And I think that, you know, I think it's really important that the supervisor also is on the alert for these sorts of things that we're talking about. Yeah. So they need to be on. They need to think about it. And they need to think, oh, okay, so you're seeing nine clients a day or she's seeing nine clients a day. Is that perhaps a bit much? Or, you know, out of those nine clients, eight of them are pretty disturbed and have got high trauma. Is that what's the consequence of that might be? See, I can't even, I can't even think about what it would be like to have eight clients that were going through quite heavy trauma. He just doesn't compute. No, that's because you've been trained in a way to think, take care of yourself to have the therapy, have the supervision. You come from an ethical, competent place. But there are therapists who put money often above everything else. Now, I feel quite sad when I say that, but I know that's true. But again, I think, you know, through therapy and supervision and, you know, the training that I've done and everything, I think I am very self aware of my own limitations. I think one or two clients like that a week would be plenty for me. Yeah, I think it's damaging both for yourself and for the other person. If you don't take all these considerations into, bear this in mind. So I hope we've not frightened anybody off Bob, but I think it's a really valid subject to discuss because it is something that a lot of us as psychotherapists will maybe teach you on the edge of in our career. Yeah, and especially beginning therapists. Yeah. I keep saying that because my hope, and I think it's true to a certain extent, that experience, and especially if the person's been in a good training program, but especially clinical experience, will teach the therapist this. Yeah. Beginning, the beginning students who start their life on placements and then in private practice, I think they're more likely to fall into this trap. Yeah. And in my experience, and again, it's because I think we have a culture where doing is stroke very, very highly. Yeah. The beginning therapists have difficulties in giving themselves permission to just being. Yeah. Yeah. I think there is a lot of that out there, though, that, you know, even the client to a certain extent in the early days might think, you know, we didn't really do anything. Nothing happened. Yeah. Absolutely. That's what I'm saying. Yeah. The problem. And partly because we live in a society, and most of the therapists and students are middle-class, and there's a huge lot of strokes for doing things and achieving things and academic success and XXX. Then, of course, they're into a situation where they think they've got to do something to be a successful, effective therapist. Well, actually, the best thing they can learn is how to be, I believe, in the psychotherapeutic process because so many clients have never had somebody who's listened to them or improperly listened to them, who've allowed them to have the space to just talk. Yeah. Yeah. Those prerequisites of a therapeutic process need to be learned, and often the therapeutic or the therapy has to go with it. Yeah. Definitely. A wise old man once said, well, I shouldn't say old because I'm talking about you, Bob. And I'm 71, but I suppose in today's world, perhaps that is old, I don't know. No, no it's not. But therapy is a process, not an event. Always. Yes. I say those words at least once a day, literally. It's so true, and yeah, you're right. So that was a good place to end the podcast. Okay, okay. So what we're going to be talking about in the next one, kind of maybe follows on from this, is what is cure for the therapist or the client. Yeah. So that we'll be doing that one next time, Bob. Until then, speak soon. Bye. Bye. You've been listening to The Therapy Show, behind closed doors podcast. We hope you enjoyed the show. Don't forget to subscribe and leave us a review. We'll be back next week with another episode.