Q&A: Burn Out Your Therapist?

Question: Can my neediness, strong attachment, and “borderline” traits repel my new and wonderful therapist?  (Photo: Marina del Castell, Flickr, CC BY 2.0)

Answer:  This is a tricky one because I can’t speak for all therapists, but I’ll share some thoughts. Technically speaking, parents should love all their children the same and professionals, who are paid adequately for their time, should give each client equally enthusiastic service. The problem is that humans are not robots and we experience each relationship differently.

Here is the good news:

The worries that seem most dire to you are probably not the ones that have the most impact on your therapist. For example, If a therapist responds well to early hints of neediness and attachment, then those qualities, which are so “disgusting” and “shameful” to the patient, are actually not a problem for the therapist. These feelings of disgust and shame reflect toxic attitudes that were internalized long ago from unloving and abusive caregivers. A therapist who felt that way about patients would probably not go into the profession and would certainly not last long doing in-depth psychotherapy.

But it is more complicated.

As has been chronicled so many times on these pages, there are therapists who can’t handle neediness and attachment. Most of those don’t present themselves as ready to do deep psychotherapy. They are more likely to identify as cognitive-behavioral therapists or to espouse a brand of therapy that does not emphasize a long-term deep relationship. Unfortunately, there have been cases of misunderstanding or mismatch where the patient couldn’t know that the therapist would reject or even punish attachment. This has happened more often with trainees, who might have the temperament to be able to handle a deep relationship, but the supervisor or the clinical director could not.

The best advice I know is to test the waters with a trial balloon or two to see what the reaction is. A therapist who competent will welcome a patient who wonders what is OK in the therapy. One who is ready to do the work will communicate willingness and encouragement. One caveat is that fear and shame sometimes cause patients to give such quiet hints that the therapist won’t notice or get what is being asked. It is important to be direct. I would recommend softening the question by using more abstract language. “I am wondering if this is a treatment that encourages talking about feelings towards the therapist?”

“Borderline Personality Disorder”

I don’t usually use that term or think well of it. Judith Herman wrote an important book, Trauma and Recovery, opening the field’s eyes to the fact that borderline usually means trauma. However, there are patients whose relationships tend to be chaotic and go from hot to cold very quickly. Often there are crises so frequent, intense, and dire that dealing with them distracts from the flow of the therapy. Perhaps most important, the therapist can be the best therapist one day and the worst the next.

Some therapists are more able to handle the crises and deal with the criticisms in an non-defensive way than others. Usually over time, therapists self-select away from this kind of patient if they have too much trouble. Here is where one of the therapist’s most important therapeutic roles is to be a “rock on the shore, battered by raging storms.” Simply by not being too reactive, the therapist brings calm and containment to a psyche in life-and-death turmoil.

One thing that makes a therapist able to do this is a perspective on what is happening. Understanding takes much of the threat out of the interaction. Another useful component is taking some pride in being able to help people who are not easy to help.

A Special Conundrum

I have written elsewhere about a special situation that happens sometimes. The patient chooses a therapist who has the qualities of acceptance and caring that were missing long ago. As the therapeutic relationship deepens, the patient begins to identify what seem to be negative intentions in the therapist that have been “transferred” from the past. In other words observations about the therapist are mis-perceived as sure evidence of say—of not caring. Now, this therapist does really care, and was chosen for that quality. Furthermore, the therapist takes a lot of pride in being a caring person. So when the patient begins to criticize the therapist for not caring, it is hard for the therapist not to feel offended and get defensive. After all, the criticism falls right where it hurts most. And, to make matters worse, the therapist’s involuntary defensiveness confirms the patient’s worst fears. Hopefully, before the investment both have put into this relationship is thrown overboard, the therapist figures out that this is all a misinterpretation and is able to help the patient see it.

When the work is taxing and difficult

Yes, there are times when every therapist has a “bad day in the office.” That is to be expected and it is why therapists need their own support system outside. And it is true that some patients are more “high maintenance” than others. It is the therapist’s job not to let any patient be the cause of “burn out.” That might mean restricting contact between sessions or not being willing to discount fees. It might mean, wisely, referring a patient out in the beginning of therapy. It might mean bringing in outside resources such as a day program or adjunctive therapy. Somehow, the balance of plusses and minuses in every therapeutic relationship will need to average out in the positive for both sides. If this balance is getting hard to maintain, it is the therapist’s job to bring this problem into the therapy and see that it gets solved. Something must be done to repair ongoing negativity. A therapist who dreads each session is as unworkable as a patient who dreads each session.

Two Basic Ethical Principles

The structure of therapy is that the patient pays for professional services that are for his or her benefit before and above all else. Within this framework, one ethical principle subsumes all others: Therapists should not make or imply promises they will not be willing or able to keep. Within these principles, is there room for therapists and patients to have a good time together? Absolutely. Laughter, warmth, enjoyment of mutual connection, pride in success, and even a feeling of power are all positive feelings that can happen for both participants, in a therapy that continues every session to meet these two ethical principles.

22 Comments

  • I was re-traumatized by a therapist with poor boundaries. I don’t have words to tell the devastation her inability to self-regulate caused in my life. I’ve been in treatment for almost two years trying to get past this so I can even talk about the original issue that brought me to therapy, to begin with.

  • I’m not sure if this post makes me feel better or worse. I think I was in this exact situation with my ex-therapist,and I worry about the exact same things.

    I saw the same (and my first) therapist for a year and ten months. About three months in, he said he thought I had borderline personality disorder, but said that he had lots of experience dealing with it, and didn’t suggest that I start seeing someone else at that time. Then, one day, he came into a regular session and told me that he thought he wasn’t helping me and that it would be best if I find another therapist. He didn’t give me any warning, no referrals, and cut off contact with me immediately. I was and still am absolutely heartbroken and traumatized by what happened. I’m not sure why I wrote all this out, or if it even applies directly to the post. I guess I worry a lot that I drove him away. I’ve tried a couple of therapists out since he terminated therapy, but I feel like I don’t even know why I’m going or what is supposed to happen in therapy. If whatever I was doing with the old therapist was wrong and, in fact, so wrong that it caused him to send me away, then I clearly don’t know what is supposed to be happening in therapy. I also feel like I am wearing a scarlet letter indicating that I am a difficult client. It is very shameful for me to tell prospective new therapists about what happened with the old therapist. I am sure they will send me away based on the past rejection.

    The saddest part is that, even though I am not sure if maybe my old therapist was a bit unethical in the way he ended things, I still would give anything to get to go back to him. I am having all these terrible, sometimes unbearable, feelings, and I only want to talk to him about them because he was the only person throughout my life who I told everything to. He was the only person I could cry in front of. Maybe I’m being overly dramatic, but the past four months have been the worst of my life.

    Again, I’m not sure if this is really a comment on the post or my own confession. Regardless, I think the response to the question posed is accurate, and I am glad that this website exists because at least it lets me know I’m not the only person who can relate to the topics covered.

  • Very interesting, Jeffery, thank you again !

    My T. just called me a few hours ago, he thought we have an appointment and i did not show up but we don’t have any today, and he acknowledged his mistake.
    I wonder what happened. I can’t help wondering. Is he confused? Am I too much? Does he face difficulties in his private life?
    I was delighted to hear his voice and to think he is thinking of me, and we took the opportunity to check our dairies and plan the later appointments, but I already worry too much about our relationship –all sorts of things— and this just adds fuel to the fire.
    It would be terrible if this is burn out, because of me.
    How it would add to the shame around my neediness!
    To the shame about me not being good enough, not lovable.
    I have been very hot and cold with him.
    I sometimes feel it is overwhelming for him. Last session we had a kind of argument and I felt I was losing him and got fearful and was devastated, but then it was all my projection, he said he was ok having an argument with me, to him it was not the end of the world.
    It sounded like the entire world is not what I think it is.
    It felt wonderful.
    But was he telling truth?

    Is he the “rock on the shore, battered by raging storms”?
    If he is in pain it hurts, I want to help him.
    But then that’s no more about me.

    What kind of adjunctive therapy do you have in mind?

    • Partial response: Regarding adjunctive therapy, for intrusive life crises, day hospital can be good. For powerful transference, Yoga, body work, self-help such as al-anon could be helpful. And I hope this blog can help a little. JS

  • The struggle is real. You’ve just reminded me how fortunate I am to have found my therapist. She accepts, normalizes, and contains my rages, projections, neediness, and ever so shameful attachment to her She’s passed all the “trial balloons.” In the “moments of change” where I once again question her caring, this will be my go to post to help remind me how cared for and accepted I am. Thank you once again!

  • As a nurse myself of 48 years I’m sure it’s very possible for a therapist to burn out. Especially after 23 years of therapy with someone with mpd / not integrated.
    And I think if the therapist is burning out with one client who has many alters perhaps she or he should have asked for / or accepted guidance from someone with more clinical experience – (especially if they have never worked with anyone with DID).
    And if the therapist is needing to discharge that client because they are burning out I think they should have the courage to try to do that in a way that is kind and without malice. Or at the very least have the professionalism to discharge with an appropriate referral in place if that client requires further treatment.
    I will never seek out the help of another therapist for however long I have left to live . I’ve been in therapy since I was a kid. I’m 69 now. So there isn’t anything I haven’t been through with therapists ……Not until I was totally and cruelly abandoned by the most loved and trusted of therapists who had helped me to become my most healthy self up until one year ago.
    Then as she burnt out – she brought me to ashes with her …

    • Hi Sharon,
      Thank you for sharing your experience. I live with DID, too. I’ve had it since I was four or five years old, but I didn’t get dxed until I was in my mid 20’s.
      I have nothing smart to say about your experience. I just wanted to send you my support your way. Although I don’t know you, I’ve been rejected by the most trusted people in my life, too, and I can imagine the pain you must be in. I know it’s easier said than done, but I hope you take a gentle care of yourself. I am sending you LOTS of healing thoughts only if you allow me.
      Echo

      • Hi Echo thank you for your awareness of my pain over the loss of this therapist .She went from being the most trustworthy person I had ever experienced in my life to being just another perpetrator who set me up for the kill. Your kind words and validation mean more to me than you know. Maybe we could somehow stay connected . Since DID isn’t something that comes up in casual everyday conversation it would be great to talk with someone about the struggle. I don’t know if this is the place to do that but – just think about how we could continue the conversation. No pressure. And if I don’t hear from you again I will be forever grateful for your reaching out to me on Dr Smiths blog.

        • Hey Sharon, a good place to check out is http://www.discussingdissociation.com
          Sorry to hear about your problems with the T. Our T is sick and in the hospital. Not the same, I know, but hurting and missing him and worrying and wondering if I caused it, etc, makes us feel very vulnerable and sad. We hope you start to feel settled and better soon.

  • Hi Jeffery,

    Wow, you sure are prescient with your articles. Either that or problems in therapy are so universal that everyone is constantly having the same issues.

    While no one would accuse me of being a high maintenance patient, I am a difficult patient–highly resistant and really not making much progress. My therapist seems pretty frustrated. He’s constantly talking about how long therapy’s going to take if I continue approaching it the way I do. Last time, he said something to the effect of “you still don’t trust me after being here with me for so long.”

    While I’ve been seeing him for approximately six calendar months (started in mid-May), during those six months, we took at least 12 weeks of breaks (two 3-week breaks and one 6-week break). So, in reality, I’ve only been seeing him for 3 months. We’ve had 18 sessions so far.
    One 3-hour session; 17 90-minute sessions = 28.5 hours. Does that seem like a long time to you?

    Anyway, it just seems like he’s trying to get rid of me. Maybe it’s negative transference, or maybe it’s real. Hard to tell.

    During our last session, I expressed (albeit indirectly) some of my fears regarding therapy and where it’s going. I had been thinking about something you wrote in one of your books–I think it’s Getting the Most Out of Your Therapy–that the worst thing that can happen from trying therapy is nothing. I had been thinking about writing you to say that, given the horror stories I’ve read both in the comments here and on this therapy forum I frequent, I’d say that the worst thing that can come from trying therapy isn’t nothing. It’s serious injury, even trauma, to the patient.

    I told my therapist exactly what I wrote above–talking about it in general terms. While he agreed with me in principle, well, he’s not an idiot, and I don’t think he enjoyed having my doubts directed at him in that way. Earlier in the session, I also flat out told him that I didn’t want to work on some of the issues he wanted me to work on because those things just didn’t seem all that important to me. While he maintained a professional demeanor and didn’t seem overtly defensive, I could tell that he wasn’t thrilled with any of this.

    Not wanting to go into Thanksgiving break with a partial rupture in the relationship, I wrote him an email telling him just about everything. (I tempered the language a bit so as to not sound completely insane.) I went through several iterations of that email, and I was proud of the end product. The first few versions contained irrelevant content, placed blame on the internet and other people, and contained veiled and passive-aggressive criticisms of him. In the end I got rid of all of that stuff. I took responsibility for my feelings and explained that if I overreacted to things he said or did it was really negative transference. (I didn’t use the phrase negative transference but explained it in more words.)

    We’ll see what comes of it. Sometimes I feel like I’m doing all the work in therapy (although my therapist would vehemently disagree and say I’m refusing to do any work).

    I’m thinking about telling him, next time I see him, that if he wants to get rid of me, he should do so now. The longer he waits, the worse it’s going to be for me. If he doesn’t think he’s going to be able to go through this process to the end with me, maybe we should just end it now.

    In many ways, it’s already too late for me. If things end poorly, I’m going to have to spend God knows how long with the next therapist–assuming I even find another acceptable one–working through the pain and injury caused by this one.

    This lady who posts on this other forum has a good analogy: she said she had a slight limp before starting therapy, and, now, after five years of therapy, she’s paralyzed and can’t walk. I really hope that doesn’t happen to me…

    Sorry about the length of this post.

    • Oh, my. I didn’t anticipate so many terrible stories. Kayla, I was obviously wrong to say “the worst thing that can happen is nothing.” Please tell me where, so in the next edition I can change that. I hope we can all think together about how to prevent such disasters. This is a real public health problem, and neither licensing, nor professional societies seem able to deal with it. Jeffery

  • It looks like my memory was not entirely accurate. What you said was, “[t]he most common risk is that nothing happens,” which is accurate. You go on to say that “the next greatest risk is a therapist who is not equipped to deal with strong feelings or challenging reenactments.”

    Sorry, I should have re-read what you actually wrote before posting. Had it been an actual critique, I would have been more careful, but I was only describing idle thoughts I’ve been having recently. But, as you can see, I have selective memory issues.

    I do remember what you wrote about the commenter who was terminated by her therapist after eight years of therapy and how that disaster should have happened eight years earlier. I had that admonition firmly in mind when I started therapy a couple months ago, and I’ve been wondering how it is that I find myself in this situation now. How did I end up with a therapist who might be a terrible fit? Didn’t I know not to let this happen?

    I think it happened because it’s generally impossible to know if someone is a good fit during the initial stages of a relationship. There’s simply no good way to divine whether someone is going to be a good therapist for you before the relationship deepens and problems arise. There are ways to minimize the risks of ending up with the wrong person, but that, too, is something that must be learned through trial and error. It’s a lot like dating, except far riskier from the patient’s perspective.

    And you don’t have to be an incompetent or unethical therapist to unintentionally inflict harm on a patient. Once you get to a certain point in a relationship, there’s pretty much nothing a therapist can do to avoid a terrible outcome. For example, if my therapist determines, in his professional judgment, that he can’t help me (a perfectly reasonable determination), what should he do? Should he continue seeing me and hope that things will miraculously work out? Or should he refer me to someone else?

    The first option simply postpones the inevitable, and it’s also ethically dubious. The second option inflicts immediate injury on the patient. As soon as he tells me I should consider seeing someone else (a much milder approach than outright termination), I’m going to be devastated. There’s nothing he can say that’s going to prevent me from being devastated. No reason. No explanation. Even if I understood his reasoning perfectly, I’m still going to be devastated.

    I don’t want to give people the impression that my therapist is a bad therapist. When I’m complaining about him, I’m focusing on the negative. The picture I paint is biased. I feel this anger towards him that just won’t go away. A lot of my writing is fueled by that anger.

    He’s really a good therapist. And I’m sure he’s been a great therapist for a lot of people. Everything I’ve ever read about him indicates that he’s a good therapist and a good teacher. His students love him. They loved him 20 years ago, and they love him now. I was careful to pick a good one this time.

    But he just may not be the right fit for me. And it’s not his fault. It’s really not anybody’s fault.

    I don’t know how licensing bodies and professional societies can possibly deal with this.

  • “A therapist who dreads each session is as unworkable as a patient who dreads each session.”

    I’m sad to say that I’m one of those patients who dreads each session. Part of me really wants therapy, but another part of me is battling against it very hard. I can’t seen to get comfortable with my therapist even after a year and a half. I’m also not very direct and have a hard time talking about anything. I have a history of violent trauma and sexual abuse as a child, but I can’t tell him about any of it. I fear that he’s getting fed up with me, but I think I would have the same problem with another therapist, too.

  • Jeffery you are so right to describe these awful traumas as a public health problem. If therapy was a drug there would be adverse effects all over it. I am so fortunate to have the most wonderful therapist but I have said to her and posted here before that therapy should come with health warnings, people think they are going into it to feel better through talk but the reality for me and many others here is pain, that can become bodily as well as emotional, real attachment issues and terror of abandonment by the only person you really feel knows and understands you. Sharon’s last comment cut me so deeply, I often feel that I exhaust my therapist but if we both went down in ashes I couldn’t survive. This must be your most difficult post to date, it’s raised such important issues for clients and therapists. I hope therapists read these posts too.

  • The way I found my therapist was so totally random– basically I took first name on the Google list. Even then, I was only going to see him so he could “fix” my 17 year old who was having some issues. I was just gonna see him for at the most 4 times and then move on. Now, 2 years later… he did help me make changes in my son. However, he also made absolutely life-changing differences in my life. He helped me see things in a way I’d never thought of before. I never realized how incredibly fortunate I was to have him be my therapist until I read some of these posts.
    As I have shared before on articles by Dr. Jeffrey, I have also become very attached to this therapist– as a father figure. But I now think it is probably time for me to move along. In fact, we have a “state of the union” meeting on December 4th to discuss this very thing–at my request. One of the main reasons I feel I need to do this though is because I am pretty convinced he’s gotta be sick of hearing me go over the same issues over and over. It is kind of embarrassing that there are some issues I just can’t get past. However, I also think I am holding onto some things so I don’t have to move on– away from him. That’s me being completely honest– and I haven’t even been honest about that part with him.
    So anyway I am glad he’s the kind of therapist that he is, but that in itself creates issues. I also just realized this may not be the correct article to post this under; I probably should have gone back to the attached to your therapist one.

    • TLC, This is the place. I am hoping people place comments in the most recent post, so the community knows where to follow, even if off the topic. You raise a very interesting question. My ambition is to do the next Q&A post on the question implied: “When is it therapeutic to let go of my therapist?” or something like that. Please don’t let me forget this. JS

      • i’m looking forward to reading this upcoming post as i am someone who had to make this decision 3 times over in my many years of therapy, the third time, although i think it was the best match, my attachment issues were not addressed & i found myself becoming increasingly self-destructive and needed to make the call no matter how difficult & leave therapy behind. although i’m someone who has made great progress alone in the years following that last go at therapy, the attachment issue never goes away & still causes me pain.. i am 52 now & the cost for therapy is a luxury i can no longer afford.. any advice on how i can keep working on the issue alone would be helpful, as would your opinion on the constellation of symptoms now commonly being thought of ‘childhood emotional neglect’ (re: jonice webb & her book ‘running on empty’) which seems to encompass the attachment issue as well.. thanks,

  • Hi Jeffrey,

    I read the posts about the terrible pain people are in because of abandonment and rejection by therapists. It seems to me, and I know it’s hard for people to hear, that they are still depending on the therapist to calm them. I know that if you were neglected/abused as a child, you do not have a foundation on which to build your life. It seems to me that all of us who have persisted in trying to get another person to soothe us, maybe do so because we don’t know how to soothe ourselves. We feel better when we talk to that special someone, (the therapist), but when we have to leave, bleeding from talking about difficult and painful subjects, we don’t really know how to care for our own wounds, and so we live in virtually unbearable emotional pain and out-of-the-box anxiety until the next session with the therapist.

    I know these things because I have seen about 70 different mental health professionals in my life, most only 2 or 3 times, but 5 of them for up to 2 or 3 years. Those all ended disastrously, but I managed to salvage myself by learning DBT (dialectical behavior training). I bought a workbook on DBT, and studied and practiced it each time I came home in terrible anxiety and emotional pain from having to leave the attention and safety of the therapists office. I have written about this before in Dr. Jeffrey’s other posts. It is really hard at first to do DBT, because you have to learn to do for yourself (soothe and regulate emotions) what you so desperately want someone else (in this case, the therapist) to do for you.

    DBT is a way to learn to deal with overwhelming emotions. It is a way to learn to calm your emotional storms and learn to soothe yourself, just like you would have done if you were cared for as an infant and young child. But since you weren’t, this book actually has written instructions about how to deal with overwhelming emotions, like those you have when you do not have the therapist there to do the soothing. It teaches you how to build an emotional foundation for yourself.

    I still read this post because, even though I consider myself to have graduated from therapy, I still experience feelings of loss for my last therapist. I sometimes still feel the pain of neglect and emotional chaos during my childhood. I also feel empathy for others who write on this blog. I now see attachment disorder as a failure to be able to self-soothe. It’s like the child who cries when his parents go out for the evening – he learns to so something soothing for himself until his parents return. He learns to interact with the babysitter. So too, those of us who experience strong attachment in therapy, because it’s an adult who cares about us, have the task of learning to soothe ourselves when the therapist is not there.

    I know different things work for different people. But Jeffrey, I wish you would do a blog on techniques for learning to self-soothe. I feel like it would help those of us who have experienced so much pain and emotional anxiety, wanting the therapist to do it for us because we didn’t learn how to do it ourselves.

    I feel like I have a life now: I’m working toward some employment goals, and I have an inner life that is mostly peaceful. I do not think about my past therapist all the time like I used to. Sure, I think about him a few times a month, but when that happens, I ask myself, “What do I need? What is the most loving thing I can do for myself right now?” And then I do that thing. I used to write emails to that therapist when I was stressed. I’m happy to say that I haven’t written in 3 months, and I no longer feel triggered to write him an email when the going gets stressful. DBT has really helped me.

    I know everyone is in a different place, their own place. So DBT might not be what everyone wants to try. But I think a post on ways to self-soothe when you are away from your therapist would really help. I wish I had learned to do DBT so much earlier in my life. I’m 55, and it would have saved me many years of agony and a suicide attempt.

    I feel for each person who writes here of their struggles and intense suffering in therapy. I’m suggesting that learning self-soothing techniques could really help calm the storm when you are not with your therapist and so they can soothe you.

    If anyone is interested, the workbook I used was “The Dialectical Behavior Therapy Skills Workbook”. The authors are McKay, Wood, and Brantley.

  • This was such a helpful post – thank you! It helped me broach the ‘A’ subject (attachment!) with my new therapist, and even though she normalised the ‘D’ subject (dependency!) I still feel a lot of shame about it which she is more than happy to work through.

    She suggested we move to twice a week therapy, which is a big relief for me. I feel a bit like a ‘serial attacher’ as I’ve had strong positive reactions to teachers and therapists in the past. This time it’s being recognised calmly and professionally and I’m feeling more at ease with it, less like I have to hide it and feel guilty, crazy and isolated.

    Thank you Jeffery!

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