The Hypocritic Oath: Depressed Therapists

Therapists suffer from depression, too. What does this mean for their patients?

Photo by Kirill Balobanov on Unsplash

Before you read another word, I want you to consider that question: would a depressed therapist be more harm than help? Yes or no?

In light of the recent (and continuing) world pandemic, this question has been much more poignant to my colleagues and I. As a profession, most of us are facing huge changes to our practice. Switching to completely remote therapy online or over the phone, no longer being able to use whiteboards in session, and -even worse- being able to adequately see and monitor our clients’ reactions. It has flipped our usual cornerstones on their head and we’ve swiftly problem solved and found ways to carry on.

Of course, with a world pandemic and the consequent lockdown measures, there is an increase in hopelessness. Precisely because our usual cornerstones (beyond work) are gone or drastically changed. No more quick hellos in the office and funny weekend anecdotes, no more change of scenery moving from location to location, no debriefs over coffee or wine (or smoothie if you are a particularly virtuous human being). These are small but substantial things that elevate our baseline mood so that from day to day we feel ok, and sometimes, even better than that.

The Oath: Do No Harm

Ok, so it’s actually the medical profession that gets sworn in under the Hippocratic oath, which is essentially the commitment to do no harm. Although psychologists and therapists are not required to declare this oath, the sentiment is explicitly and intrinsically bound in the guidelines of accrediting bodies around the world. For a UK psychologist, this would be the regulatory standards of the Health and Care Professionals Council (HCPC) and the British Psychological Society. There may be additional guidelines from the specific therapeutic regulation bodies that the practitioner practices within. For cognitive behavioural therapists in the UK, this would be the British Association for Behavioural and Cognitive Psychotherapists (BABCP).

The British Psychological Society conducted a 2016 survey finding that 48% of psychologists reported having felt depressed over the last week. This was an increase from 40% in 2014, showing that there is a rise in poor mental health amongst the profession. As we haven’t seen an almost halved workforce within the field, or a near-doubled amount of complaints and court cases against psychologists, evidently there are a lot of psychologists still working effectively whilst experiencing depression.

So picture the therapy room: A depressed client, a depressed therapist both coming together to try and alleviate the client’s depression. What do they both have in common beyond that goal? The idea that they are no good. While that can manifest in us all, in different ways, for the therapeutic relationship, often that manifests in the therapist working extra hard to ensure that they don’t let their client down. The other thing both client and therapist share in common? The fact that this belief of being no good is neither fair nor accurate. A quick sum, and what this equals is: a totally competent therapist working even harder for you because they believe they are no good. And I really don’t mean to be flippant here. From my professional experience, this is what I observe to be true.

Hypocrisy

If you are depressed how can you legitimately enable someone else to sort out their own depression? Isn’t that like someone who’s broke telling someone how to get rich?

Absolutely not. A more fitting analogy is a yoga teacher with a broken leg, continuing to instruct. Therapy is about the process. The personal reflections that the client is enabled to make and the growing empowerment to be able to make those changes. A therapist with depression can still facilitate this when they are depressed. They are still able to help the client look for the pieces of the puzzle so that the client can slot them in place. Depending on the degree of the depression, there is no reason for the therapist’s own half-done or jumbled up one, to enter the therapy room.

Shared Hopelessness

Depression is on a continuum — as with all mental health. And we may fly up and down that continuum on any given day, week or month. Many people with depression are completely functional, although everything feels a lot harder. People may not even realise that they have depression because they are so functional! The lack of pleasure in usual things, the increased agitation and irritability, the desire to sleep more (or inability to sleep at all) — these are all things assigned to “stress” or a dip in mood. That’s not to say that’s not necessarily true, but where these experiences persist, perhaps only getting lower, that’s where the slippery slope of depression lies. This is wonderfully illustrated by a quote from a participant in a study looking at “hidden” depression in older people in the UK.

“…people don’t talk about it do they, they think it’s a weakness don’t they? But it is something that you can’t help when you are in it, you know as I say you don’t realise you are going in it and as much as you try you know sometimes you can’t get out it, it gets deeper you know.”

As mental health professionals, it may not be so hidden to us, but that is not guaranteed of course. Emotional avoidance can be a really automatic process. For the most part, therapists will deal with their own mood and depression in the same way they would encourage their clients too. As mentioned, the therapist is likely to be acutely aware of whether their mental health is impacting on their ability to help their client. An integral part of psychological practice is regular supervision. This allows another set of more removed and objective eyes and ears to make suggestions in the course of therapy; a safety net for any therapist blind spots, if you will. It also means that there is an opportunity for the therapist to reflect upon their own feelings from delivering therapy and to process this where necessary. This is the forum for therapists to consider how their therapy is being impacted by their own mental health.

For example, when mood is more pervasively lower, making it hard to concentrate and step back, when negative filters are in full swing, it might be nigh on impossible to help be that objective alternative hopeful perspective for your client. If this is the case, it is up to the therapist and their supervisor and/or manager, to decide what are the best courses of action. This might be timely annual leave. It might be a reduction in caseload. It might be therapy for the therapist. Or a combination of solutions. In short, there are professional checks and balances to prevent the mental health of therapists detract from their efficacy in delivering therapy.

Self-Disclosure & Empathy

The degree of therapist self-disclosure varies across individual therapists and schools of therapy. Aaron Beck, the grandfather of cognitive behavioural therapy, encouraged the use of self-disclosure to facilitate clients’ own discoveries. His daughter, Judith Beck, is also an advocate of self-disclosure as a therapeutic tool.

“Self-disclosure often gives them a different way of thinking about their problems. And it goes a long way in strengthening our relationship when patients recognize that I am a human being who is willing to share something of herself to help them.” Judith Beck

Judith gives examples of how she has incorporated an alternative perspective or action in her own life: instead of “I should always do my best”, she proposes “I should try to do a reasonable job, a reasonable amount of the time”. I, personally, go one further, not with all of my clients but with some. I confess I know exactly how it feels to have the thoughts close in and there seem to be no way out and just how debilitating that feeling is. I too, know what it is to push myself until I have nothing left to give. To wonder if it is all worth it. Yep. Had all of that and it feels horrid. As I say, I don’t disclose this as a matter of course in my therapy sessions but I do it where it appears useful. Here’s how it helps:

  • It gives hope. If I have been there before and found a way out too, they can too.
  • It normalises. If I have felt like this and yet can be here and present in this room, then it maybe isn’t a sign of complete inadequacy.
  • It builds trust. If I have felt like this, I hear them and can empathise with the deepest understanding.

Superhumans

Historically, therapy has involved an imbalance of power, whereby the therapist holds all the cards and may be put on a pedestal as an all-knowing, wise superhuman. We can thank Freud for that. However, with the rise of more evidence-based, collaborative approaches like cognitive behavioural therapy and acceptance-commitment therapy, increasingly therapists are seen as collaborators. Teammates with a different set of knowledge and skills to support you to acquire them too.

While clients may put their therapists on a pedestal, perhaps even more problematical, they put their idealised selves on pedestals. “You shouldn’t feel like this,” “you should achieve this”. Inherent in these assumptions is the denial of permission to suffer along the way. And denial or resistance to suffering is denial or resistance to what it is to be human. The more we can acknowledge that part of being human is to have vulnerability, to not always get things right, to have fluctuating moods and things we need to figure out (on an ongoing basis), the more we can lean into our own experience with ease and contentment.

So back to the question: can a depressed therapist help you? What is your answer now? Has it changed from when you first started reading the article? From my point of view, the answer is a resounding yes, although admittedly I am biased. I have many wonderful colleagues who have and have had their own experiences of mental illness and I would not think twice about referring a client to them with a glowing, heartfelt recommendation.

Dr Sula Windgassen is a health psychologist working in the NHS and researcher at King’s College London https://www.instagram.com/the_health_psychologist

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