Episode #147

Being a therapist is badass. We are depicted as cardigan-wearing, somewhat nerdy, mild-mannered intellectuals or touchy-feely, overly sensitive, preschool teacher-esque guides for adults. The reality of our jobs is far grittier and messier than people expect. Sure, some of our clients are pretty highly functional. They don’t all have dark, painful histories  and it can sometimes be relatively simple to help someone get back on track. 

We might “sit all day and listen to people,” but that is not the easy task people think it is. We witness, we observe, we sit with, we absorb, we voluntarily walk into people’s storms and confusion and sit down to take it all in. That is badass. Who else deliberately sits with people’s pain and let’s in sink in. Do they keep doing it everyday knowing that they will carry the weight with them? That they will have nightmares on occasion because of something someone told them? That they will remember, sometimes permanently, some of the fucked up shit that happened to someone that isn’t even related to them? We choose this. We choose to go into the storms with people. We have to stay grounded and help them find the way out. We not only do it everyday, we do it for decades. Is it any wonder we burn out? Ours is sacred work and it puts us at risk for compassion fatigue, burnout and secondary traumatic stress.  In this episode, I talk with Vicarious Trauma Expert Dr. Jenny Hughes about what is so hard about our jobs and what research tells us we need to protect ourselves.


 You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

 Welcome back to the All Things Substance Podcast. This is episode 147. So last week on the podcast, we talked about two different topics. The first one was about how trauma and substance use are bi directional. Now, maybe that was common sense for everybody else, but when I found out that the research came up with that, that was a big deal to me. The research has told us now that trauma is a risk factor for substance use, and at the same time, substance use is a risk factor for trauma. What it tells me is that substance use really is showing up in all of our offices, whether or not we know it’s there or not.

In the second episode last week,  I talked with you about five reasons that therapists tend to shy away from screening for substance use. And then I shared with you five compelling reasons about why I think you should assess for substance use.

All of this, of course, is leading up to the event Braving the Course that’s coming up a week from today on September 18th at 6 p.m.  Dr. Jenny Hughes and I presented Braving the Course at the end of last month and it was a success. We did hear from folks who weren’t able to attend live, and we heard from folks who were wanting CEUs. And so we got together and started talking about what could we make happen. The only way for me to be able to help grant those CEUs as a CEU provider is to have people attend live. And so Jenny and I decided to present again on the chance that there will be more folks who can attend live.

During this event, we’re going to be talking about vicarious trauma and vicarious resilience. Those are both super important concepts that we need to know because they affect our work and our very ability to be therapists. Jenny and I both feel really strongly about helping you succeed in your job, in your career, and doing the thing that you love without sacrificing who you are.

Secondarily, I want to share my top three screening questions with you to help you get started talking with your clients about substance use. Today, what Jenny and I want to talk about  is what happens when therapists start to get compassion fatigue, head towards burnout, and what it is that contributes to that. We’re not just going to talk about the problem, though. We are going to end up talking about the solution because believe it or not, there are solutions to this and it isn’t just to become a real estate agent. 

So today I’m going to welcome Dr. Jenny Hughes, who is a good friend and colleague of mine, as we have done a lot of these together now, and this is her area of expertise and we want to share this with you in preparation for Monday night, Jenny. Thanks so much for being here. Thank you for having me back, Betsy.

I have been on a number of trainings that you have done. And so I know what you mean when you talk about VT, vicarious trauma, and when you talk about vicarious resilience. But I want to have you share with my listeners more directly about vicarious trauma, secondary traumatic stress, compassion fatigue, burnout. And I wonder if you can start there and just explain it like I’m five. 

Of course. All of those concepts, it’s interesting, a lot of times they’re used interchangeably both just amongst us as therapists and also in the literature but they are also their own unique experiences for us as therapists. And I have put them together in a little model that I call the trauma therapist trauma response. It’s relevant to any kind of therapist. It could just be the therapist-trauma response as well.  and we’ll talk more about this at braving the course. 

But if you think about it as a continuum, it starts with vicarious trauma, VT, and it starts there because vicarious trauma is honestly, a natural thing that happens to us in our work as therapists, we are empathic humans, and we are doing the work of helping and healing. And that means that we are going to be sponges and we’re going to soak up the stress and trauma that we are seeing in our work each day. That is not in and of itself a bad thing.

It’s actually good. It means that you are empathic that you’re doing your job. It starts to cause problems, though, when we aren’t able to ring out that VT sponge. When we aren’t, don’t have the skills, the support, the things that we need to ring out our VT, then it can start moving down this continuum and turn into…

The compassion fatigue, which is when our cup is empty. We have nothing left to get right. If we continue down that continuum, we are still not able to address the compassion fatigue. Then it can turn into secondary traumatic stress. Secondary traumatic stress is interesting because anyone can technically experience secondary traumatic stress, whereas with vicarious trauma and compassion fatigue, they are unique to people who are in helping and healing professions.

But with secondary traumatic stress, we start to have PTSD like symptoms of our own that are related to our work. So like we can’t, more than like we can’t stop thinking about a client, it’s that almost like we’re having. Like flashbacks of things that we were hearing in session, or we’re starting to feel like we’re always watching our back because of the type of work that we’re doing.

And then the last part of that continuum is burnout. And if we’re not addressing the VT, the compassion fatigue, the secondary traumatic stress. That is when we reach the point of burnout and burnout is when we feel like we have to jump ship to save ourselves. Like the only way that we can keep going on as a human would be to leave this profession.

And it’s not that it is a bad thing in and of itself. To stop being a therapist or to stop being a helper and healer. The problem is when we feel like we’re forced to do it because we have burned out. And that is what I work so hard to do with therapists is to support them both in their healing, but also then in their ability to make informed choices about what they want to be able to do with their career or become a real estate agent if they want to, if that’s what is going to work for them.

It was a really important concept for me to understand that those are all different things and that it’s a continuum or a process and that it wasn’t one thing because when people ask are you burned out, it feels like if you say yes, you’re burned out. That’s like the end of the road and knowing that it’s a process and being able to identify where people might be on the spectrum, I think is helpful.

So what is it that contributes specifically to this process of heading towards needing to leave the field? Cause I know that there’s been research on it and I wonder if you can tell us about what those factors are that they found that were most impacting therapists. 

Yeah, so there’s a number of top factors that can affect these things. So the type of work that therapists do can definitely be a risk factor. So people who are doing trauma work are going to be more likely, for example, to experience higher levels of vicarious trauma. And so they’re going to have to work harder to wring out that. Sponge so that it doesn’t turn into other things like compassion, fatigue, burnout, et cetera.

Interestingly, and I say that because in a minute I’ll tell you the other side of this, but when we have as therapists, perhaps our own history of stress and trauma that can put us at greater risk of this continuum accelerating a bit faster. But the biggest predictor of burnout is lack of support and organizational factors.

Those are often overlapped in the literature and more commonly you’ll see research talking about organizational factors predicting burnout. But what that looks like are spaces where therapists are working and they are not feeling supported. They do not feel safe. And They feel alone, even when they’re surrounded by other therapists.

So as you’ve started working with therapists, talking about vicarious trauma and resilience, what have you noticed about where people are in this process? Do you feel like the majority of people have been all the way at the end of the road? Are they somewhere in the middle? I wonder if you have any sense about where the folks that you’ve interacted with, where they’re at on this. 

Just like so many things in psychology, it depends. I always hate that. But if I were to make a generalization, people are certainly further along the continuum towards burnout. Most of the people when they start working with me in the Brave Trauma Therapist Collective, they’re not just at the top where they are, ringing out their VT and just managing what it is like to be a therapist and to have natural reactions to the kinds of work that we’re doing. A lot of folks are in that compassion fatigue, or even secondary traumatic stress part of the continuum.

 And there are definitely people who are close to burnout. The unfortunate thing is that once we are really close to tipping the scales towards burnout, it can be really hard to seek out help, to ask for help, to accept help when it is in front of us, because we feel so hopeless about things.

We are at that point where we’re needing to jump ship into the life raft to just save ourselves. So again, for that reason, I hope to be able to catch therapists before those skills are teetering or even tipping over into burnout, because I’d rather take a preventative approach approach and help to connect therapists together in community to fill those spaces where their organizations or their group or private practices are not providing that support and that connection. I want them to be able to really understand the concept of vicarious resilience and how our clinical work with clients can be rejuvenating in and of itself.

I want to be able to reach people and therapists at the point where they are still feeling the excitement and the joy in their work, even though it’s starting to feel pretty heavy.

When I’ve worked with therapists either as clients or as a supervisor when they’ve been hitting compassion fatigue or at burnout, it seems so helpless and difficult to come back from and to change. Of course, prevention is always where you get more for your money when you’re talking about prevention in almost all areas that I can think of, but once people are already in one of those difficult spots, they can come back out of it. We can’t of course promise what that would look like or necessarily know if it’s possible for everyone, but that there are things that can be helpful.

I’d like to talk about the antidote here for lack of a better phrase to finding yourself in that place or feeling like you might be heading in a direction where you’re starting to get the Sunday night dread or even more.

I remember once having a job where I left on Friday and I only worked two days a week at that job, but on Friday night on the way home, I would dread having to go back on Thursday. That’s a problem, and when I realized that even having five days away from there, I was like, oh, fuck this, I gotta go.

And when people start having that fuck, I gotta go to work, and it’s not just the oh, I don’t feel like working, I would like to do something else. But instead, it’s about the work, like that is a really rough thing. And so I want to talk about the opposite side of that coin. 

So when people come to me and they are at that brink of burnout, they’re ready to jump ship. The place that I start with them is figuring out just what is the first step. And that can be just really overwhelming and feel like a lot in and of itself.

Oftentimes, the first step for people is needing a space where they can be seen and heard. They are perhaps working in an environment where they’re not feeling supported, or maybe they run their own private practice and they don’t have outlets and connection with other therapists. And so being able to create or find a place where they are going to be seen and heard can be a really powerful first thing to do.

It’s funny because as I say this, about Oh, it’s just about connecting with other therapists and creating community and all of that in a way, it feels like It’s not enough. Even me, the person that runs the Brave Trauma Therapist Collective, because I know how helpless and hopeless it is to be right at that brink of burnout and how it feels like nothing is going to help. And if you told me like, Oh, we’ll just go and connect with colleagues. I would have told you to go fuck yourself. 

And I also know both from the research and from my experiences with other therapists that it is an antidote, similar to what our clients do. A lot of times they will come to us and they’ll say teach me the skills that I need to be able to heal from my trauma or fix this problem. My response is sure, I can teach you skills, but that doesn’t actually mean that you’re going to use them or that they will even be helpful. 

The healing that happens in therapy, what we know across therapeutic orientations and interventions, is through the therapeutic relationship. And the power and the healing that happens in between humans. This theme holds true for us as therapists. And I know how hard it is to practice what we preach. I am not perfect at it by any means. And it is in that community and connection with other therapists who get it, especially for trauma therapists, where we can’t necessarily even talk about the kind of work that we do with people who don’t do trauma work.

Being in a space where you know that you can just show You can say what you need to say. You can provide support for others as well and have that reciprocity. It’s really healing and you get to start to carry the weight together. So we’re distributing this work and we’re not just carrying it alone. And that can really be as a first step, it can actually turn into a huge leap in whatever direction that therapist wants and needs to take in their career.

I’m a huge fan of the research that came out of the Menninger Clinic  about the therapeutic relationship being the biggest reason why people get better. I just hadn’t thought about applying it to ourselves, but of course it does. That of all the things that we do, all of our interventions, all of our everything that is the main reason that people get better, is the quality of that relationship.  

You and I have talked before about what it’s like being a trauma therapist. And when you tell people you work with trauma and the responses that you get to that from Oh, Oh, wow. Good for you. I’m so glad you do that, or whatever the case may be. And for us, there’s an internal bracing, I think, that a lot of us do, and maybe even we don’t say the word trauma, but we say we’re a mental health therapist or a therapist, and I’ve seen all over where therapists are like, I don’t tell people, because then they start telling me things, which is accurate, even if you don’t say you’re a therapist, sometimes people just tell you lots of stuff that has no business in the middle of a a grocery store being talked about on an airplane, right? Yep. 100%. 

And I think people’s response to hearing that we work with trauma or hearing that we work with a difficult population, whoever that is. I get the same response when I say that I work with adolescents with drug problems. I get a very similar response. I’ve also heard from people who work in hospice or who work in other types of difficult types of therapy positions that It is other people’s response. It feels really isolating and it feels really disconnecting from them because we are, we’re holding a lot of stuff and a lot of darkness. We did sign up for this. We did choose it. 

And I don’t know that our programs were designed for. In fact, I know they weren’t designed  to help us not just survive. But thrive in this career, they taught us in ethics, how to avoid getting sued and how to avoid getting your license pulled, but not necessarily what about the rest of it and can anyone ever really explain to you how to be present emotionally and distant enough, and that we just didn’t get a lot of that information.

And I think what they do is they train us as they’re supposed to, that’s what academia is supposed to do, and then they send us out and then it’s the field’s job that’s supposed to help us figure out how to live that way, but the agencies are focused on making ends meet and meeting quotas and standards and all sorts of things. And so who is taking care of that other part of us? . I think that’s why what you’re doing is so important because you’re providing a space that doesn’t exist. It seems like in our later career, so not so much our early, first beginning, but that each of us have figured out oh, if I have something I need, then it’s up to me to find it. 

And I know that when folks are in the place where they’re struggling. Whether it’s with VT or compassion fatigue or burnout that it is difficult to see what they need or to have the energy to do. 

And I think that also is reflected in the work that you do, Betsy and being able to help therapists learn how to address the substance use that their clients are already probably doing, whether the therapist is really aware of it or not.

But it’s not just about the skills that you are teaching them. Like I said earlier, oftentimes when we’re burnt out, We think that we just need skills to feel better just like our clients you are teaching them invaluable skills, but you’re doing it also in a space that where there is community that is created and fostered and where people know that they can show up and be vulnerable and ask all the questions because they’re learning.

New things and they are taking a leap into doing something in their practice that maybe they had shied away from intentionally. I’m an example of that where for the longest time I have always been like, nope, I don’t work with substance use and honestly becoming friends with you and colleagues with you has helped to change that for me and has given me the ability and the confidence that I needed to be able to start stepping into that more in my own practice as a trauma therapist.

But again, it’s through that community and through shared experiences and knowing that you are coming to a place where people are going to get it. You don’t have to describe all the backstory. You don’t. Have to sugarcoat things or protect people and they’re not going to be judging you, they’re going to be open and accepting and they’re learning right along with you and you have cultivated and created that space in your program with Charting the course.

It’s one of the things I love the most about what we do is when I can feel that somebody specifically, but also the group is actively engaged and on the same page, there’s something about it that feels really cool and satisfying also for me, where I feel like what I’m trying to tell people is, hey, this isn’t as complicated. I promise. It is not as complicated. You’re not going to get in over your head. You really do want to know what you’re doing. Let me help you. Let me show you a little bit. And I had that experience during one of the modules and the last cohort. And it was just really neat to watch people be like, Oh yeah, I could do this or I could do that. And I’m like, yeah, you can. And having the ability to say, okay, when somebody brings this up don’t immediately panic if somebody talks about something with a substance, listen, get the parameters, and then if you still have a question, then let’s talk about it. Ask me and I’ll say, Hey, this is what I think, or maybe we need to know about that thing. 

And I think it is, there’s partially doing the training, getting the information, which is I think important, but then having the follow up. I know for myself, when I did EMDR training, as well as TF CBT, that the follow up was As important, if not more than the actual training, the training was important. I needed to understand how to do the techniques, but having the consultation calls and being able to follow up and ask questions made it.

So those things were actually useful for me that I actually remembered to use the different skills and ask the certain questions. Because it wasn’t lost in, I just did 110 sessions this month, or whatever it is, and I don’t remember a damn thing from any training I ever went to. 

I think you and I both, even though our programs are a little different in that sense, that mine is more about this very specific set of information and training, but that we have both skills training, but also the support that goes along with it so that the people that are involved and the people that are involved in both of our programs, they have like bookends of support. Where they know they can go to you if there’s a specific thing and they know they can go to me if there’s a specific thing and I think . It’s just been really magical, which is part of the reason why we came up with Braving the Course to begin with, was finding a way to combine the work that we do, better support folks.

Yep. And to, like you said, have the bookends on each of these different kinds of work, knowing that they are overlapping, that they are feeding into each other and bi directional like you talked about earlier. 

Yeah. It’s been really cool. And what I want to share with folks listening today is that this, the information that Jenny shares with you on Monday really I think is important. And if you’re not at a place where you resonate with heading towards compassion fatigue or even burnout, I am very happy and excited for you and I want you to have the information so that you can see, Oh, yeah, it’s because I’ve been doing these things because I’m willing to bet that’s where it is that.

For whatever reason, whether it was intentional or not, there are some things that you’ve been doing that have been  helping to protect you in this work. And for those of you who wonder if you’re heading in that direction, or those of you who 100 percent know that you’re in those places, the information that Jenny has for you is super important.

It was something that… While I had seen lots of examples of compassion, fatigue, and burnout, that I didn’t notice it as a process and I didn’t really know about how to intervene or what to suggest because the answer that people have is self care and self care has become, while I think it’s an important concept, a little bit like the word mindfulness and when somebody says it like it’s the answer to life, God and everything, it’s frustrating and it feels invalidating, even if it’s accurate.

Our brains shut off because it has become weaponized in a lot of ways to where, Oh, you just need to take better care of yourself, right? Like you’re burning out as a therapist because you’re not taking care of yourself well enough, right? So it’s your problem. You have to fix it. It’s a you problem that has nothing to do with me. Yep. 

What I have found through the information that I’ve watched you present and talked with you about over the last year and a half, has helped me see multiple places in which things could get better for somebody and that all problems, they’re multifaceted and multi maintained that nothing is one cause and nothing is fixed by one thing and so I think looking at it in a more dynamic and varied way, I think is really important. 

So I want to share that next Monday night. So a week from tonight at six o’clock, we are going to be doing Braving the Course. And Jenny will present first and share the information that I’m talking about. And then I’m going to present second and be talking about screening skills for substance use. Sharing the top three questions that I think are useful and you can even get CEUs for attending. 

The information about the CEUs is on my website. So it’s betsy byler.com/braving-the-course. And that’s braving B R A V I N G. We really hope that you join us on Monday. Jenny and I are excited to present this training again. And are hopeful that many of you are able to attend live and are able to get a sense for what this could be like for you and what it would be like if you ended up joining our programs through the bundle that we have for you. And we’re excited about just all of it. 

So Monday night, get yourself registered and we hope to see you then. And until then, have a great week. 

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

Braving the Course Registration betsybyler.com/braving-the-course

Home of the Brave Trauma Therapist Collective braveproviders.com

Charting the Course betsybyler.com/course