3.4 Stress and Burnout in the Counseling Profession

Despite its potential to be a gratifying vocation, counseling is challenging and emotionally demanding. Practitioners are expected to bear witness to the stories and consequences of many of the most heartbreaking aspects of the human condition with historically little to no personal support. Furthermore, agency resources remain low, demands on practitioners remain as high as ever, and external pressures from managed care organizations often result in dilemmas for counselors that can restrict their ability to provide ethical care if not handled correctly. The following section details some of the unique stressors counselors face, with an extensive portion detailing the ongoing epidemic of burnout in the helping professions (O’Connor et al., 2018; Warlick et al., 2021).

An additional note that warrants explanation before starting this section is that given the constructional similarities and interrelationships between many of the stressors we discuss, such as burnout, compassion fatigue, and vicarious trauma (Cavanagh et al., 2020; Figley, 2002; McCann & Pearlman, 1990; McNeillie & Rose, 2021; Sinclair et al., 2017; Velasco et al., 2023), we have decided to include a separate section on self-care, coping strategies, and protective factors rather than providing recommendations for each individual phenomenon. This saves you, the reader, time and provides a comprehensive section on self-care literature and exercises that you can return to later in your clinical practice. The primary downside of this organization is that the following two sections present an unfairly bleak outlook of the counseling profession in focusing solely on stressors and counselor impairment. Keeping this in mind, we encourage readers to either read through to the end of this chapter in a single sitting or jump around between sections if you find yourself feeling stressed out about navigating these future stressors as practicing counselors.

Common Sources of Stress in the Counseling Profession

Compassion Fatigue and Vicarious Trauma

Compassion fatigue and vicarious trauma are two interrelated terms used to describe potential counselor responses to repeated work with traumatized clients (Cavanagh et al., 2020; Figley, 2002; Joinson, 1992; McNeillie & Rose, 2021; Velasco et al., 2023). The term compassion fatigue has had an interesting history, first being coined anecdotally as a term used to describe symptoms resembling burnout among nurses (Joinson, 1992) before later being developed more empirically by the pioneering work of Charles Figley (2002) as a result of his observations in working with traumatized veterans following the Vietnam War. As it is understood today, Compassion Fatigue is a syndrome consisting of anxiety, emotional numbness, preoccupation with client trauma, and a reduced ability to empathize effectively with clients resulting from repeated exposure to trauma narratives (Cavanagh et al., 2020; Figley, 2002; Joinson, 1992).

Though research on the topic is still somewhat in its infancy, some identified risk factors for the development of compassion fatigue include personal stressors and life disruptions, repeated exposure to trauma narratives, past traumatic experiences of the counselor (particularly those that are unresolved), low organizational and workplace support, and having limited experience within one’s field (Figley, 2002; Sinclair et al., 2017; Velasco et al., 2023). Though prevalence estimates among helping professionals have yet to be established due to a lack of a standardized and accepted construct of compassion fatigue (Sinclair et al., 2017; Velasco et al., 2023), symptom patterns resembling our presented construct of compassion fatigue have been found to occur in all helping professions regularly (Cavanagh et al., 2020).

Similar to compassion fatigue, the notion of vicarious trauma came to light as a result of McCann & Pearlman’s (1990) work with survivors of trauma. Rather than focusing on a pattern of symptoms, Vicarious Trauma is concerned more with the alterations in cognition that result from repeated exposure to trauma narratives. It is defined as the alteration of cognitive schemas in line with that of traumatized clients such that the counselor perceives the world to be more untrustworthy, unsafe, and uncontrollable (McCann & Pearlman, 1990). These schematic alterations can lead to numerous emotional, behavioral, and psychological effects, such as hypervigilance, emotional blunting, and hopelessness (McNeillie & Rose, 2021). Like compassion fatigue, the notion of vicarious trauma is considerably challenging to measure accurately. There is no widely accepted empirical measure of vicarious trauma; instead, contemporary research uses modified versions of PTSD metrics that ask counselors to answer based on indirect rather than personal trauma (Velasco et al., 2023).

Scholars have voiced concern with this method, however, as personal trauma histories of the counselor may impact these responses, thus inflating any prevalence estimates (Buchanan et al., 2006; Velasco et al., 2023). Keeping these methodological constraints in mind, a recent meta-analysis examining 10,000 clinicians across 52 studies found average vicarious trauma scores reflecting mild to subclinical symptomatology among mental health professionals, seemingly establishing vicarious trauma as a mild to minimal concern for most counseling professionals. This is not to say, however, that vicarious traumatic reactions do not occur. Buchanan et al. (2006) found that over half of their sample surveyed experienced impairing effects related to vicarious traumatic reactions. However, 60% of this sample had experienced past abuse themselves, which may have made them exceptionally vulnerable to these reactions (Velasco et al., 2023). Furthermore, a recent meta-ethnographic review (A manualized synthesis of a type of qualitative literature) identified many instances of clinicians whose lives had been severely impacted by vicarious trauma (McNeillie & Rose, 2021).

Though vicarious trauma may not be a shared experience among counseling professionals, when it does occur, it can be incredibly distressing and thus warrants careful consideration (McNeillie & Rose, 2021). The primary risk factors for the development of a vicarious traumatic reaction include high exposure to trauma narratives, which may occur at a greater rate in settings such as crisis centers, specialty clinics, and community mental health agencies, as well as past traumatic experiences of the counselor, especially when similar to those experienced by the client (McNeillie & Rose, 2021; Velasco et al., 2023). Furthermore, while not risk factors in themselves, experiences of burnout and compassion fatigue may be significant correlates and warning signs for the later development of vicarious traumatic reactions, given the conceptual and symptomatic overlap of these phenomena (Velasco et al., 2023).

Blurring of Work and Personal Boundaries

One common factor generally apparent in most stressors identified in this chapter is a blurring of work and personal boundaries in the counselor’s life—whether emotional, temporal, or physical. The burned-out counselor may find themselves struggling to sleep at home due to dreading a session with a difficult client the following day. The counselor neglecting self-care may leave the office only to spend the evening at home updating client documentation on their personal computer. Moreover, the counselor who may be overidentifying and feeling responsible for clients may give out their personal cell phone number for out-of-office crisis calls (Speaking of which, it is our position that the responsible counselor should never use a personal cell phone for work with clients. We will provide alternative suggestions on this topic in Chapter 17). Though many counselors enter the field from a desire or calling to enact positive change in their communities, allowing this to be the sole mission that consumes all of one’s life dramatically increases the risk of burnout within the field (O’Connor et al., 2018; Yang & Hayes, 2020). Taking time for one’s self, friends, family, and personal life is as much the hallmark of an effective counselor as their work with clients, as evidenced by the significant ethical codes’ emphases on self-care (ACA, 2014; NAADAC, 2021) as will be explored in greater depth in Section 3.6.

Role Strain

Role strain is a unique stressor within the counseling profession, as rather than arising as an emotional consequence of client care, it tends to emerge due to various conflicting societal systems attempting to interface with the counseling profession. Role strain occurs when two of the counselor’s primary stakeholders place demands on the counselor that appear irreconcilable. This can be a common source of ethical dilemmas for the counselor. A typical example of role strain among counselors working with involuntary clients is the duties of beneficence and nonmaleficence to the client juxtaposed against the duty to the court to report honestly about the client’s progress. A counselor may be obligated to report that a client has missed their last three appointments to the court despite the knowledge that this means their client will be sent back to jail, likely negating months of therapeutic progress. Similarly, counselors may experience role strain in balancing their duties to the client with parents/guardians, third-party payers, or workplace policies. Role strain in some capacity will likely occur for all counselors throughout their careers. However, it is particularly prevalent in forensic and non-voluntary settings such as jails, prisons, psychiatric wards, and community substance use treatment facilities.

Burnout

Burnout came to light in the 1970s due to the confluence of two unique cultural developments in American society. Following the end of the Second World War, the American government and policymakers set their sights inward. They began more extensively monitoring and regulating traditional “helping” professions such as medicine and social service agencies (Schaufeli et al., 2009). According to Schaufeli et al. (2009), one consequence was the bureaucratization of careers that had once been considered personal callings. The social service worker or practicing counselor found that rather than altruistically helping others, they were expected to meet quotas, run businesses, and comply with complex state and local regulations. This formalization of the helping process proved disillusioning for many idealistic providers as the personal missions and values that once motivated them clashed starkly with the demands of organized and regulated care agencies. Parallel to this, the ongoing American “War on Poverty” motivated many young and idealistic Americans to begin a career in the helping professions (Schaufeli et al., 2009). Though some positive change was enacted, this political campaign ultimately came up short in addressing many of the systemic factors that perpetuated poverty in American society, which led to what Schaufeli et al. (2009) termed a “frustrated idealism” in many human service professionals as they felt incapable and unsupported in enacting the societal change they had dedicated their lives to. These factors: the formalization of the helping professions, persistently excessive demands on practitioners, and a disillusionment with one’s work in enacting meaningful change converged into the concept of burnout similar to how we understand it today (Schaufeli et al., 2009).

Burnout is defined as a syndrome of “emotional exhaustion, depersonalization (sometimes referred to as cynicism), and (feelings of) low personal accomplishment” (Maslach et al., 2016, p. 1). It is generally understood to result from a similar confluence of factors that Schaufeli et al. (2009) identified. However, additional risk factors for the development of burnout in clinical practice include conflicts between organizational and personal values, carrying a more significant caseload, a decreased sense of job control, working in an agency setting, and being of a younger age (O’Connor et al., 2018; Schaufeli et al., 2009; Yang & Hayes, 2020).

Current prevalence rates for mental health practitioners experiencing significant levels of various forms of burnout are estimated at roughly 40% (O’Connor et al., 2018; Warlick et al., 2021), with the majority of practitioners reporting impairing emotional exhaustion and 20% of practitioners reporting impairing depersonalization, cynicism, and feelings of reduced personal accomplishment. Interestingly, clinical practice is not necessarily the impetus for burnout among mental health clinicians, with a recent study by Warlick et al. (2021) finding that graduate students in clinical training programs experienced burnout rates similar to those of practicing clinicians.

These findings are incredibly worrying, given the effects burnout has been documented to have on clinical practice. Salyers et al. (2015) interviewed 120 mental health clinicians in the United States and found self-perceived burnout to be associated with numerous self-perceived impairments in 58% of clinicians, such as decreased quality of work, poorer outcomes for clients, social withdrawal, reduced empathy, and decreased energy and creativity. Furthermore, a recent qualitative literature review by Yang and Hayes (2020) found burnout among clinicians to be associated with decreased job satisfaction, increased absenteeism, and increased job turnover among employees.

Viewing these impairments in the context of everyday practice, there is potential for numerous ethical missteps ranging from providing clients with substandard care to client discrimination and boundary extensions and even client abandonment. We will explore this concept of the impaired counselor in greater detail in the following section.