It feels strange and redundant to explicitly write about self-care as I think everything I’ve ever written, every thing I’ve ever posted, the act of writing itself, is an attempt at caring for and preserving myself and my own experience.

We often talk about “self-care” as if it is a simple, regulated and hygienic act, like or lighting a candle and running a hot bath. And sometimes it may include those things.

That was certainly how my professors spoke about it in our practice classes in social work school: When they asked us about our “self-care plan” as new professionals heading out into the field, most people spoke about their restorative hobbies, their yoga or exercise practice, some spoke of their own therapies or spiritual and religious lives.

I used to think about self-care in similar ways: as the things I did outside of session to fill myself up so that my tank would be full when I returned to the work the next day, and emptied myself again. An endless cycle of setting myself aside and returning to myself, of emptying and filling, of exertion and refueling.

Healing the wound that the work made contact with every day: the compartmentalization of my own self and my own needs, the injuries sustained while working with clients who struggled with their own aggressions, and traumas. Recovering from the vicarious traumatization that I would then be exposed to the next day.

To that end: I meditated, I exercised, I went to therapy and supervision, I took vacations. I read. I wrote.

One of my earlier posts from the blog told the story of a “secret keeper” whose job began to slowly sicken her. Finding creative ways to release these secrets and share them with the community at large raised her from her sick bed.

And psychotherapist’s needs and energies are not fixed, and our self-care and self-preservation practices must evolve way beyond reparative/restorative work. Self-care needs to become part of the air we breathe, a daily, moment-by-moment practice – one that informs every clinical intervention if we are to offer any model to our clients to help them escape their own moral masochism and self-neglect.

“Moral masochism” is a notion that Freud began to discuss later in his writing. Many people associate “masochism” with sexual practices and behaviors that associate pain with sexual arousal. “Moral masochism” refers to the far more common association between equating withstanding pain with sustaining love and attachment.

One of the most important lessons I learned in supervision – was when my supervisor at the time followed me out of the office to hand me an empty disposable water bottle that I had unconsciously left on her coffee table.

“Here, you forgot this” she said, handing me my garbage.

And I watched her over the years, in the waiting room – “hand back” various detrius to other supervisees and clients:

“You forgot this” – pointing to a tissue they had left on the couch and summoning the client back to retrieve it and deposit it in the trash themselves. Passing back an unused napkin or two, or a paper coffee cup.

The message was clear: I will help you hold your shit during our scheduled appointment but I won’t ultimately take ownership of your garbage. Your garbage belongs to you.

I was never able to guard my own boundaries quite as vigilantly, and I still cannot. Whether I should or I shouldn’t – I toss the waterbottle in the bin myself, I pick up the dirty tissue with another one.

But I do keep in the front of mind the larger lesson in that, and about all of the ways that psychotherapists are trained and conditioned to “hold the garbage” that belongs to others. How that training not only begins in our early familial experiences – but becomes an explicit mission of the helping professions, as we live out “social work values” or discuss the importance of “client-centric care.” And too often I supervise psychotherapists who have been told that the pinnacle of professionalism and empathy is to be able to “set themselves aside” to serve even the most challenging of clients.

A therapist cannot do more than his personality allows. Yet we are called upon to try to do more. We are called to keep stretching, if we can – if we can take it. Often we break, splatter, die out from fatigue, come back, regroup, begin again. Nothing stops us, especially failure, not even the hostility or admiration of patients and colleagues. Our own heaven-hells push us further into reality and keep on pushing. ~ Toxic Nourishment, Michael Eigen

Here Eigen, whether he realizes or not, is writing about a kind of “moral masochism” that encourages psychotherapists to “sacrifice” their own needs and comforts for our client’s sake, and with the belief that it is ultimately the most altruistic and self-actualized path to choose. And perhaps it is in some circumstances, but there are times when the breakage, the splatter, the fatigue are a signal that something is not right, something is profoundly out of balance in the therapeutic relationship, and that the treatment itself is moving into spaces that are pathological for both the therapist and the client.

Studying martial arts further drove home the lesson that there are times to assert your energies and press forward, times to retreat and defend, and times to simply hold your ground and block.  I wish that psychotherapists could be trained more explicitly in the processes of healthy self- and other- respecting self defense.

But maybe we only learn, as in martial arts practice, how to calibrate the allocation of our energies after we have absorbed many painful blows.

Last seminar I wrote about incomplete and unexamined myths, and one of the damaging underlying shadow-myths of psychotherapy is masochism and martyrdom.

Agency, hospital and institutional practice often compounds this by placing clinicians in impossible and self-injurious circumstances: carrying enormous caseloads, making dangerous home visits without escort or back up, leaving psychotherapists and care providers working with impulsive or potentially aggressive clients unsupported, and blaming unsupported therapists when dangers do emerge.

Psychotherapists who have no say in their caseloads, or who are not allowed to transfer or close cases without “permission” of the administration often find themselves working with clients that are more than challenging, – badly matched clients may be damaging, or sometimes even legitimately traumatizing to the psychotherapist.

Psychotherapists may expose themselves, out of this unexamined masochistic mandate, to clients who may develop destructive obsessive fixations, who may develop homicidal fantasies, who may rage at their therapists in ways that leave therapists feeling threatened or verbally abused. Some work in setting with clients with histories and capacities for physical violence.

Clients who are caught in an entrenched negative therapeutic reaction can claim and eventually demand more and more from a therapist, sometimes while coercing the psychotherapist caught in a web of personal and professional “moral masochism” to provide more and more support, phone calls, emails, for less and less reimbursement, and with diminishing therapeutic effect.

Walking the line here is a fine and fuzzy one. There are many client’s who need and do clearly benefit from a therapist’s abidingness, patience and compassion during regressive phases of the work. Clients do need us to sometimes “stick with them” though period of irritability, hopelessness, or impulsive acting out. But generally we can see that they are able to reorganize and reconstitute in ways that both the client and the therapist can identify as a clear therapeutic “gain.” Client’s who will not benefit, who are entangled in a negative therapeutic reaction for whatever reason: the tangled nature of their own history or a damaging “ill-fit” between client and therapist – will generally continue to get worse, and become more destructive to self and other in proportion to the support that is offered.

These are clients that psychotherapists need to practice active self-care with for both the therapist’s and the client’s sake. These are the kinds of cases that agencies need to hold firm limits with, and place therapist and staff safety and well being above the client’s – understanding that not everyone referred to services will benefit from them – and more importantly – that some people will fare far better without psychotherapeutic support.

Like my supervisor “handing back the garbage” as a symbolic gesture communicating that she would not permit clients or supervisees to engage in a destructive “negative therapeutic reaction” in her care – Marie von Franz, one of Jung’s direct “disciples” tells a story of a client that Jung told her to terminate with for just these reasons:

Jung said… if one gave psychic energy to anyone, one should always see what they did with it. If there was a slight, or momentary recovery, even if that collapsed again, one could go on giving compassion or concern, giving energy to the case: while if it had a contrary effect, then one would know that one was feeding the demon of that person and that the person didn’t get what one gave… It was as if her evil animus were sitting in front of her mouth, and whenever one gave her a good bit he got it. In effect the demon got fatter and she got thinner.

 

In such a case if one goes on treating the person with Christian charity, love and concern, one is acting destructively, that is a mistake which many naïve young psychiatric doctors make. In their Christian tradition, but also in the tradition of medicine (Hippocratic oath!) it is absolutely imperative that one always be charitable; such people don’t notice that they are feeding the devil and making the patients worse instead of better. Therefore, if one sees that the devil snaps up everything one gives, one can only do one thing – turn off the tap and give nothing. ~ von Franz, Shadow and Evil in Fairy Tales

 

And because we aren’t perfect, and because we are entangled in an unprocessed professional masochistic myth, and because we are capable of attachment and compassion towards clients who legitimately need us to negotiate periods, sometimes long periods, of discomfort or conflict we will sometimes misjudge who is making good use of the treatment and who is ill-using, or is ill-served by therapy itself. I wrote this essay about swimming with clients in these dangerous waters, and the inevitable injuries that will be sustained as a result of our imperfect judgment.

But this is why it is also essential that supervisors, teachers, mentors in this field explicitly restate to emerging clinicians over and over again that self-care IS client care. This is the message that we need to communicate to our colleagues, our peers, our students, our supervisees. We must support each other in making sure that all of our client care is also grounded in self-care.

 

One more time:

Self-care is client-care.

 

Allowing a client to behave destructively, even in subtly destructive ways, toward their therapist is both damaging to the therapist and a disservice to the client.

It is often said that psychoanalysts suffer from a narcissistic disturbance… This can be confirmed not only inductively based on experience, but also deductively from the type of talent that is needed by an analyst. His sensibility, his empathy, his intense and differentiated emotional responsiveness, and his unusually powerful “antennae” seem to predestine him as a child to be used – if not misused – by people with intense narcissistic needs. ~   Alice Miller, Prisoners Of Childhood

Here, Miller is talking about the ways that therapists themselves, their personal histories and psychological/historical morally masochistic predispositions lead them to become psychotherapists, and the ways that therapists may allow themselves to be ill-used by the clients in their care.

A kind of “moral masochism” is a danger not only to the well being of therapists, but to our clients, as it may restrict our willingness to confront clients firmly about relationship/treatment destructive behavior and bind our “appropriate responsiveness” – leading us to minimize or over empathize with clients’ devaluing or damaging behavior.

The frequently encountered “need to cure” on the part of the therapist evolves from the need to repair the narcissistic hurts from his own childhood attempts to deal with impaired significant early figures. This leads the therapist to regressively reexperience the felt need to provide ego sustenance for such needy significant objects. Guilt reactions paralyze the analyst’s appropriate responsiveness and intensify the masochistic provocations of the patient or lead the analyst to be “giving” rather than interpretive. ~ Glick & Meyers, Masochism: Current Psychoanalytic Perspectives.

Not all “moral masochism” is without value – we all need to be able, at times, to marshal our altruism, delay gratification or withstand sacrifice and discomfort for the sake of another or some larger goal. There are many ‘normal’ non-pathological enactments of such forms of masochism:

In short, minor manifestations of “moral masochism” are an almost unavoidable correlate of normal integration of superego functions. The sublimatory capacity to endure pain as a price (by means of hard work) for future success or achievement also has an underpinning in this generally normal masochistic predisposition. ~ Glick & Meyers, Masochism: Current Psychoanalytic Perspectives.

 

Another way of discussing this idea, is to examine the ways that psychotherapists are susceptible to being driven by an overly punitive and harsh super-ego:

The “superego” features of the depressive-masochistic personality are reflected in a tendency to be excessively serious, responsible, and concerned about work performance and responsibilities. These patients have a somber quality and are overconscientious. They are highly reliable and dependable and tend to judge themselves harshly and to set extremely high standards for themselves. Glick & Meyers, Masochism: Current Psychoanalytic Perspectives

 

The outcome can be a psychotherapist who takes on too large a share of the “guilt” when there are conflicts in the psychotherapeutic relationship.

The analyst whose development has been skewed into the path of needing to give is prone to guilty responses when his suffering patient complains he has not been helped enough. The analyst often responds to these complaints with silence or passivity. He may have the analytic aim of stimulating the patient to reflect on what he is doing or to facilitate the patient mobilizing his repressed anger. Often, however, his behavior reflects his need to suppress his own annoyance for fear of creating a sadomasochistic collaboration. As expected, this can only complicate the analytic work. ~ Glick & Meyers, Masochism: Current Psychoanalytic Perspectives

 

“Supressing his own annoyance,” professional and programmatic mandates to make sure that services are client–centered and “do no harm,” a characterological sensibility that leads one to be able to over-extend on the behalf of others, an over-developed sense of guilt, a “need to cure,” all these combined with the fact that sometimes some manageable degree of masochism is exactly what some client’s require of us in order to heal – can lead psychotherapists into hot and self-injurious waters before they are able to recognize it.

 

Racker (1968, p. 179) has emphasized how the masochistic analyst may be inclined toward submission to the patient, particularly to his resistances. Such a therapist tends to allow the patient to be in charge, even letting himself be tortured and used, so as not to frustrate the patient. However, all incentive for therapeutic zeal should not be disparaged, even if it does stem from a core of masochism in the analyst’s personal history. It can also serve a positive therapeutic value in fueling the patience and devotion necessary for the long and difficult tasks of analytic work. ~ Glick & Meyers, Masochism: Current Psychoanalytic Perspectives. 

This, is why, in my mind, the primary function of administrative and clinical supervision must be first and foremost to try to compensate for this multi-determined myth of masochism – and to try to assure that the psychotherapist is caring for themselves sufficiently – moment by moment, case by case, in session and in the therapeutic environment – while they are “on the clock.” – and not merely attempting to make themselves whole again with “self-care activities” after work hours. Too often, in my view, instruction, training, and supervision serves to undercut psychotherapists in the process of self-care. When the therapist is treating themselves with sufficient self-compassion and self-respect, the client has a healthy model of relatedness that allows them to imagine non-damaging connections to others.

It is also essential that we remain realistic and humble with regard to our belief in the powers of psychotherapy. We cannot cure everyone. Not everyone is well served by us individually, or even by the “right” psychotherapist (if we happen to be the wrong one) Psychotherapy as a practice is not able to help everyone, and we must acknowledge, even as we believe in what psychotherapy has done for us, for others, and for the clients that we have served well, that there are people who will do better without it. Even some “very troubled” people who others imagine “need therapy” to get better – may in fact, live better lives without ever engaging in psychotherapy at all. If we are not cognizant of the our limitations, and the limitations of the profession itself, we will harm clients who would be better off without us.

Disrupting or terminating a toxic therapeutic relationship, “rejecting” a client who is doing damage or being damaged by services (and often these are often the same thing) is a way of refusing to “do harm” on a deeper level.

Its also important to remember that a psychotherapists capacities can ebb and flow through different stages of their lives. A challenging client whose regressive or aggressive energies are well tolerated by a psychotherapist at one phase of their lives may flood the therapists capacity to be both self- and other- compassionate at a different stage. The types of clients that I could nurture before I had children for example, were not necessarily the same kinds of cases that I could serve effectively while I was exerting myself to care for two small children. The clinical conflicts that I could negotiate skillfully with self-respect and with empathy before my cancer diagnosis became overwhelming to me when my own capacities were reorganized by fatigue and a new sense of fragility. I wrote about that in this essay as I prepared to return to work last spring.

It is important to recognize, that no matter how healing, and rewarding, and essential the power of empathy is, that it has a masochistic shadow, one that, the more conscious of it we are, the more able we are to negotiate its dangers. And moreover, that this kind of “moral masochism” is not avoidable. It is inherent, it is in our beings, it is embedded in the gift of empathy itself, and the seat of our “impossible profession.”

For ill, and for good:

Since we cannot expect much positive reinforcement by praise of out relationships, our zeal can have a powerful value in preserving our own self-esteem regulation, in providing inner resource of gratification and pride in our work, that is, approval by the ego ideal. Olinick (1969) uses similar reasons to explain the baffling phenomenon of the analyst’s dedication to this “impossible profession” ~ Glick & Meyers, Masochism: Current Psychoanalytic Perspectives.