After certain sessions practitioners worry: “Perhaps I should have kept working. Did I use enough pressure or too much? Should I have focused just on the area of pain? Should I have said what I really thought was going on? Maybe I should call the client to see how he/she is doing. Maybe I should refer him/her on. Should I have charged her less since she was so upset? Was she upset at me?”
Ours is a caregiving profession and as such we struggle with a dilemma all caregivers must deal with: how to balance the quantity and quality of care with the client’s ability to care for herself. How do we know when we’ve given enough? When are we taking on too much of the client’s burden? I believe that the issue of unconscious and unnecessary caretaking is central to how our profession defines itself. It is a complicated issue because taking care of others, easing their suffering, is a natural and commendable human trait. The issue is also an ethical issue because taking on the burden of care for another is fraught with the possibilities of control and manipulation in both directions.
In the first article in this series I outlined what I consider to be the origins in our backgrounds of unnecessary caretaking as it shows up in our practices. I argued that the primary reason for burnout and lack of success in our profession is that many of us who are drawn to bodywork have pasts that predispose us to taking over the care of others whether appropriate or not. I offered working definitions of caretaking and caregiving as they apply to our work with clients.
What is Caretaking? Caretaking is: taking over treatment or care of a person who cannot provide (take over) care of himself. In bodywork, caretaking can be temporarily very helpful for the client in distress. Practitioners at times may assume a caretaking role when clients are experiencing physical, mental, or emotionally instability and do not feel up to making their own choices. As caretaker the practitioner takes on the responsibility for the choices, goals, and outcome of treatment. Caretaking is inappropriate when it derives from the practitioner’s need to be needed when it fosters client dependency.
What is Caregiving? Caregiving is: giving care, aid, help, assistance, treatment, and/or attention to a client. There is no obligation on the part of the caregiver to produce certain results. Our chief obligation is to be as present to our clients and the therapeutic process as possible. The receiver of care remains fully responsible for his/her own care process, including the choice of practitioner and goals of care.
Because of their early conditioning, caretakers are usually unaware of the unhealthy signs and symptoms of unhealthy caretaking that show up in their practices. The purpose of this second article is to point out some of the indicators that may otherwise be overlooked by practitioners.
Here is a list of the warning signs or symptoms of unwarranted caretaking as it shows up in our lives and our practices.
- Fear of Taking on the client’s symptoms: Practitioners who have a strong fear of taking on their clients’ symptoms while feeling a strong need to take care of their clients’ problems, may over-identify and feel the client’s pain viscerally.
- Sublimating or suppressing our own symptoms: The practitioner’s own body symptoms and emotional crises disappear while working with clients but return later. We become focused upon the client’s issues in lieu of our own. If our issues start to show up while we’re working we may dissociate from them.
After practicing full time for twenty years Judy moved to a new state. She can maintain only a very small practice. The body symptoms she suppressed while working so hard to help her clients have become so pronounced that she hurts for hours after each session. Much of her musculature and joints ache and burn. Sad that she may have to stop working altogether, she cries openly and bitterly.
- Physical symptoms of caretaking: We feel symptoms accumulating in our own bodies from overwork: anterior rotation of shoulders, rhomboid spasms, carpal tunnel syndrome, varicosities, and tight quadratus lumborum. All professions have their negative consequences on the body. It is ironic that the practitioner takes on many of the health problems she has been relieving in others.
As a tutor and teacher for bodyworkers I have observed many practitioners giving sessions. Painful physical symptoms from treating clients arise in large part due to poor body mechanics and to working too hard to “fix” the clients’ problems. The practitioner will often “get into” the client’s pain and holding patterns by bending over, assuming a bent posture of carrying the client’s load: shoulders anteriorly rotated, the weight of the upper torso, head, and arms borne in the mid-thoracic region. Pauses and breaks are neglected during and between sessions especially when there is a run of “needy” clients.
- Self-sacrifice versus self-care: Compulsive caretakers have great difficulty with their own self-care and maintenance. They are poor at maintaining good physical and emotional health. Accustomed to putting off their own care, and feeling ashamed and guilty about their own bodily symptoms, they rarely seek the consolation or support of others.
Alan, a practitioner who graduated from massage school four years ago, has a thriving practice. He never slows down; his phone rings continuously with new clients. He is pleased to have such a thriving practice, such a busy life. He does not turn down appointments; “I can squeeze you in” is his response. He has not received a session from another practitioner in months. “I don’t have time. My days are taken up with clients and the needs of my family.” He has not taken a vacation in over a year. “We just can’t afford it... training workshops are my only time off.” He is in continuous pain in his mid-thoracic region and his traps are rock hard. His wrists bother him a lot. The muscles of his hands and forearms never relax He leaves home at 8am and often doesn’t get home until 10pm. He is afraid to slow down, ripe for burnout.
- Client dependency: Practitioners feel safe and validated when they have a large number of clients who keep rebooking. However when clients indicate that they cannot get by without our regular treatments, the picture may not seem so healthy. We may unconsciously promote client dependency by our need to fix. With dependency comes a burdensome feeling of enmeshment with the client.
- A fear of intimacy in the practitioner: Often we focus on symptoms as a substitute for being fully present to our clients. “I am afraid to get too close to the clients for fear that I will lose myself.” The caretaker fears her boundaries will be compromised so she works mechanically to avoid intimacy.
- Difficulty staying present and focused: Dissociation (spacing out) during the session. If we find ourselves feeling fearful, going numb, leaving our bodies, having conflicting thoughts, being disoriented during sessions rather than staying present, it could be a sign that the bodywork is disabling to our psyche. We honestly do not want to be providing care for others, especially those who trigger fear or other discomforts inside of us. It is hard to admit that we have negative even scary feelings about our work. At the same time a compelling voice inside keeps saying that we cannot do anything else.
Marilyn, a practitioner, who suffered sexual abuse as a child, has struggled to maintain her practice over the years. Her body feels weak. She is often tired and depressed. “When I work I find myself zoning out, becoming spacey.” She is very passive in her approach to life and in her practice. In the beginning she saw lots of male clients. She found it difficult to deal with males who sexualized the touch she was giving them. Now she works only with women. “I’m not really sure if I’m doing anything for my clients. I don’t have any other way to make a living. I can’t afford psychotherapy.”
- Substituting control for flexibility: In a caretaking regimen the practitioner as technician applies various methods and protocols in order to gain control over the symptoms and change them. Each session is based mechanically on the achievements of previous sessions. The caretaking practitioner has to have an answer, be in charge, know what is happening and ultimately take responsibility for the outcome of the session.
- Difficulty with financial arrangements: Caretaking can be reflected in our lower-than-average fee structure, in our willingness to work clients beyond the arranged time without charging additional fees, in our neglect of collections for second party compensation, by our difficulty selling our services, and in our difficulty with raising our rates. It is often easier to subsidize our clients than to deal with feelings of self doubt that come up around money issues.
Ask yourself whether you have had difficulties in these areas. Remember the inner torment you felt when you knew it was time to raise your rates, when you had to speak to a claims adjuster about the delay of your reimbursement, when you decided not to charge your client for extra time because she was still in pain at the end of the session.
- Poor professional boundaries: We maintain professional boundaries in order to sustain a healing context that is safe, dependable, and nurturing for our clients and ourselves. The following situations are signs of inadequate professional boundaries: over-identifying with the client, over-sensitivity to the client, playing dual roles or a seductive role and/or sexualizing the relationship.
- Carrying the burden of the session: The inability to let go of a client or the results of the session when it is over. The practitioner continues to ruminate about what did and did not happen in the session. These are the kinds of thoughts that get triggered especially when we think that we must produce certain results for the client or we have failed.
- I am my role: Another related symptom is over-identification with our role as healer/practitioner/therapist. We feel insecure and so we inflate the importance of our professional roles to prove that we have value to others. Caretaking is a natural outgrowth of this need for self-importance.
- Lack of referrals, fear of competition: Feeling competitive and suspicious of colleagues, the caretaking practitioner rarely refers clients to other therapists. “They will steal my client or discourage her from therapy.” Feeling inferior because “newer practitioners have more energy and better training,” older caretakers resist helping new practitioners get established because they see clients as a scarce commodity.
- Professional isolation and stagnation: Most bodywork practitioners are sole proprietors and thus have to go out of their way to confer with peers. As caretakers we already feel overwhelmed by the burdens of our work, thus we maintain few if any peer/professional relationships. Professional training and continuing education requirements seem like a never-ending challenge to keep up with others. Caretakers wind up feeling sad, lonely, depressed and isolated.
- Envying the client: The compulsive caretaker may feel jealous of clients for the time, money, and opportunities they are able to create for receiving bodywork. As a sole proprietor the compulsive caretaker will often forestall her own nurturing, claiming scarce resources and time.
- Addictive habits and caretaking: Caretakers maintain an illusion: they get their needs for love, security, and nurturance met by the rewards of helping others. “Goodness is its own reward.” The truth is that most experience chronic loneliness, depression, and sadness which they sooth with addictive substances and habits such as overeating and workaholic behavior.
- Difficulty receiving from others: Caretakers are actually afraid at a very deep level to receive care from others. This is a very difficult symptom to admit to oneself or others. It is very difficult for caretakers to relax and receive without analyzing, judging, or controlling the experience. Placing ourselves in the care of others, letting go of control, becoming childlike, trusting to something deeper than our own minds, letting go into the unknown; this is at the core of our fears.
- Becoming the authority figure: We are tempted to play the role of “expert” or “authority.” Clients want to entrust their own authority and responsibility to the practitioner. The more authority and responsibility we accept, the more of a burden we carry: we are rewarded for giving sound advice and removing symptoms; we are blamed for unsound advice or when symptoms remain.
- Messiah, rescuer complex: Caretakers often unconsciously tout themselves as the practitioner of “last resort,” the one who has all the answers. This tendency reveals the practitioner’s need to be right, to be in control, and to take over others’ care as a way to guarantee their own livelihood and safety.
Brenda, a ten-year practitioner with quite a successful practice, starts every conversation with her clients and friends with, “How are you doing?” followed by a solicitous query about, “Are you taking care of yourself?” Her tone of voice implies that she is very concerned that people’s symptoms could get much worse without a session from her. She has difficulty keeping her professional identity within boundaries. This is partly because everyone is a potential client. She sees herself as a caretaker in all relationships. She sighs a lot as she worries about her clients. Her own body is regularly wracked with pain. She has great difficulty relaxing and trusting other practitioners’ work and rarely receives bodywork.
- The ageing helper: The pattern of taking care of others while not receiving care from colleagues and protégées becomes even more entrenched with older caretakers. I have seen this in quite a number of elder health care providers. All bodies age and become symptomatic. The aging process is humbling to all of us, and ironically, professional pride as health professionals can make it difficult to own our own symptoms. We operate under the paradigm that symptoms are the enemy, that symptoms are evidence that our clients have done something wrong or that something wrong has been done to them. We then lose face as we become symptomatic. We must have done something wrong.
Summary
In large part the above caretaking symptoms are due to our commitment to bear the burden for removing, and sometimes taking on the unwanted symptoms of our clients. We accept a healing paradigm that describes the symptoms of the client as pathology that must be excised - by the practitioner if possible. Rather than viewing body symptoms as part of the client’s path to self-understanding, we buy into the culture’s tendency to blame the body and eradicate the symptoms. By accepting this formula we learn to overlook our own body stories even though we feel the consequences physically and emotionally.
But what if we were to focus our attention and that of the client on the symptoms as pathways to a deeper reality? What if both practitioner and client were to follow those symptoms as they evolve in response to our attention? What if we were to view each session, each client, and each body part as an opportunity to explore the unknown territory of true healing?
These observations about caretaking derive from frank conversations with colleagues and years of practice. I speak about this subject not as an expert but as one who has learned by difficult experience about the pitfalls of caretaking. The next articles in this series will deal with, the addictive nature of caretaking, and solutions to the dilemma of giving compassionate but appropriate care.
© Jack Blackburn, 2001
