Bec* first came in for therapy for burnout. She was a psychiatric nurse and worked at a public hospital in an inpatient unit. She sobbed during our first session, full of guilt at having had to take leave after collapsing in tears during a shift. She said she was letting her patients and team down by being away. The strength of Bec's anguish at letting people down felt disproportionate to the circumstances, and I noticed that she wasn't concerned about her tears and collapse, just about the impact of her time off on others.
I probed deeper, trying to understand this.
Bec said she'd been working very long hours, usually pulling double shifts a few times a week. She was proud of her work ethic and said that always being available to her team and patients was important to her. She seemed to derive most of her identity from her professional role. While she had a partner, she was often too tired to see her girlfriend, or to socialise with friends or exercise. She was often stressed because of her long hours but felt too guilty to make any changes and kept pushing through her tiredness and stress, until the day she broke down crying.
It felt important to understand Bec's relationship with work in the context of her underlying personality traits and the beliefs she had formed about herself. Often, when people are over-invested in work, they have a psychological makeup characterised by themes of self-sacrifice, abandonment of their own needs, perfectionism, enmeshment with others and the need to "earn" their place in the world.
We spoke about Bec's early life during our first few sessions. She was raised by a single mother who had a serious mental illness and difficulties with addiction, and was repeatedly admitted to hospital. Bec was her mother's carer from the age of 13, managing appointments and medication, soothing her mother and remaining attuned to her moods, remaining alert to the possibility of overdose, and helping with daily tasks. She developed great empathy for those who were unwell and said that she had a strong desire to help others, leading to her decision to train as a psychiatric nurse. She'd been praised from a young age for being so "mature, kind and giving", and she had learned that her value lay in these qualities.
Bec had almost no emotion in her voice and body language when she told me about her childhood. She seemed nonchalant about her mother's difficulties and dismissive when I reflected that becoming a carer at a young age would have come with struggles, such as missing out on important adolescent experiences or being able to live free of worry.
"It is what it is," she said, and this was a line she would repeat multiple times throughout our therapy, each time I touched on anything sensitive.
Bec's difficulties struck me as difficulties that had been decades in the making. While she was 45 when she saw me, her patterns of overwork had commenced as soon as she started working as a nurse. She over-identified with this role and told me she couldn't sleep at night when clients were not doing well.
Bec's pattern was typical of the archetype of the wounded healer. Many people drawn to helping professions such as nursing, psychology or paramedicine have experienced difficulties in life that have predisposed them to wanting to help others as a way of finding their own healing. They often re-enact early patterns, such as self-sacrifice. The wounded healer has been hurt but has not engaged in any healing work. They may try to resolve their own hurts by helping others.
While people with this pattern can make excellent clinicians and healers with great empathy and sensitivity, this is usually facilitated by self-discovery, insight and good boundaries, and engagement in recovery work. When the wounded healer pattern is unrecognised, the outcomes can be disastrous with malignant behaviours, such as positioning oneself as a saviour, working to the point of collapse, or breaching boundaries with patients.
As therapy progressed, Bec and I started to explore the messages of self-sacrifice she had unknowingly absorbed. The day she spoke about her sadness at having missed her school formal because she was caring for her mother was a turning point. We could then start to speak about the role of children in a family and the impacts of being parentified. We worked on emotional recognition and healthy lifestyle management, as well as boundaries.
We needed to do a lot of work with the part of Bec that felt guilty for holding boundaries, as well as the guilt she felt when talking about her resentment toward her mother. We encouraged regular rest and worked on helping Bec understand and meet her own emotional and physical needs.
Her progress in therapy was slow as the ground we covered was vast, but this work allowed Bec to have a more realistic appraisal of the importance of work, and to nurture an identity outside the self-sacrificial healer role.
* Bec is a fictitious amalgam to exemplify many similar cases that I see