Episode 32: Sleep, Competence, and Supervision: When Therapist Fatigue Matters with Pamela Young

Welcome back to your Clinical Supervisor’s Couch podcast. And I’m your host Kayla Das.

In today’s episode, Pamela Young, registered psychotherapist and clinical director of Hope Harbour Psychotherapy will discuss when therapist fatigue matters and how it can impact our clinical practice.

Hi Pamela. Welcome to the show. I’m so glad to have you here today.

Thanks, Kayla. I’m a registered psychotherapist, like I say, in Ontario and the clinical director of Hope Harbour Psychotherapy. We’re mainly online, and then a year ago I opened an office in Belleville, Ontario. So now we have a location where clients can come in person.

I have an amazing team of therapists. We have the six therapists that work with me and an intern. So my clinical work that I do besides running the clinic, is working mainly with trauma therapy particularly EMDR and working with clients who are carrying a lot of complexity and emotional load.

I actually came into supervision somewhat by accident after 15 years ago. Very persistent individual kept asking me to supervise their internship. I initially hesitated, but eventually agreed and that experience really changed the direction of my work. I provide supervision both internally and externally to various psychotherapists.

And over time I discovered that I love supervision in some ways, even more than the therapy work itself. I’ve made a lot of mistakes in my own practice and I also love to learn, but I think that what I love most is supporting therapists, is they’re developing their skills and finding their voice and growing into their own way of being a therapist. That’s been incredibly meaningful to me.

I really appreciate that and I love that you shared that you hopped into clinical supervision by accident because someone really valued your approach and you know what you bring to the field. And I think that when we think of clinical supervision, although it’s required by many of our regulatory bodies. It really is about having that person who’s been there who understands whether it’s your clinical approach, your therapeutic modalities, the theoretical orientation that you work from, but to have that person who’s been there, done that, being able to help guide you through it so that you can really integrate what you’re learning into practice. And sometimes I think we forget that. We think it’s just like this check mark but it really is about building our skills further.

Yeah, absolutely. I think, that’s so true and my goal isn’t necessarily to create little duplicate cookie cutter panelists who do therapy the same way that I do. But it’s helping the therapist to take the practice or the modality or their personality.

And also to help them to identify the strengths of that, but also the weaknesses or the blind side or the things that they may not be noticing. Just that outside observer. And I still value that myself with my own supervisor after all these years. There’s times she’s gotta come and say, you know what, Pamela, you’re missing the mark. What’s going on here?

I can completely appreciate that. Now, I know one of your kind of specialties is working with clients who are experiencing sleep related issues. So when we think of, therapists and, supervisees, why does sleep matter ethically for therapists, not just personally, but like in the professional realm?

Yeah. When we think about ethics, we mainly think about boundaries, the consent that we have to get from clients, the documentation, but ethics also lives in how we show up in the therapy room. it’s our attention to and our awareness of what is our own internal experience that is happening as we are working with the clients. So that could be our own personal emotional regulation or our capacity to respond thoughtfully rather than reactively. And when we’re not sleeping or we’re not personally getting enough hours of sleep, it’s really hard to be totally present and clinically responsive.

And, I love the CRPO in terms of their conversation around the effective use of self. And this is where I see this ethics about sleeping well. It’s really understanding what’s happening internally in us. And the effective use of self as a therapist is about knowing our own nervous system capacity. And we know that a lack of sleep reduces our cognitive ability and it narrows our window of tolerance. So when we’re tired we can become more reactive, less flexible. Sometimes it’s harder to stay emotionally present with the clients in that moment in the therapy room.

There’s an organization that’s called the Green Cross Academy of Traumatology, and a lot of people aren’t aware of this group, but they work alongside the Red Cross, which goes into the emergency kind of situations. And what they do is provide support for the first responders and those responding to the trauma. With the emotional support and ensuring that they’re able to show up and do their job and they actually have a document that you have to sign to do the work with them. And it’s an ethical guideline that’s very clear about the importance of the self-care.

It’s considered from their, document that it is unethical not to attend to self-care, which is a big, area to look at. But one of the things they explicitly name in that is having adequate sleep as part of maintaining a professional wellness and effectiveness. So this matters. In the therapy situation also, because within, therapy, as we have to have that sustained attention. We have to have the emotional attunement and that ability to respond non-reactivity to really intense material. So when a therapist is chronically sleep deprived those capacities are really hard to access for ourselves. And so even for myself as skilled clinician. I notice it when I’ve not had my sleep. And it is really part of our professional responsibility.

Absolutely. And this is more of a situational experience that I’ve had. But, when I had my daughter, and I can imagine any parent out there, understands when you have a newborn sleep is just not happening for you. And if I can think about, some of the symptoms that I experienced, now I will give a caveat that I did take five months off. So I wasn’t working with clients at this point. But like memory loss, I guess this goes in with memory loss, but, not remembering, what I did last, or not being able to comprehend what is being said around me. Like I’m more like on survival mode and just getting through the day versus really taking in what’s being said.

So I can imagine, just using that as a potential example if someone is experiencing chronic sleep deprivation, that those symptoms plus more maybe even a larger scale, would happen and how would that influence one, the client relationship, but two, the client care that’s happening within the therapy room. Are we missing things? Are we remembering things or are we forgetting things? And these are all of the things that I’m thinking about, even just looking at my own experience of being a new mom. It definitely took a toll.

Yeah, I love that example. And that’s a great situation where this isn’t about, being a poor therapist or, not doing it right or that type of thing. I don’t want people to feel shame when there’s just natural life circumstances. I recently just had this experience with just one night of being very poor.

And what happened was we were traveling and just what often happens in the travel, our flight got delayed and there was weather and snow and we had to basically be 24 hours up and then the next day I had to see clients and I knew I was operating with lack of sleep, and, showed up to work. I was going to see the clients. I was talking to some of my team members and I noticed internally I wasn’t tracking what they were saying. I wasn’t following them, and they actually even called me out on it like, are you okay to see your clients ’cause you haven’t really slept very well. And I actually called it, it’s not fair to them to show up when I’m just cognitively not present. And so I ended up canceling my sessions for that afternoon because the reality is that therapy is mentally demanding work. And so when a therapist isn’t sleeping well, like when I wasn’t sleeping well, or you have this little one that’s waking up in the night we get this double hit, the parts of the brain that we rely on for planning for judgment and tracking those complex materials is not functioning well.

And at the same time, the other parts that are related to our emotions and our reactivity, they stay switched on. So part is switched off and part is switched on. And so practically that shows up in a few ways. It becomes harder to track narratives across the sessions. It’s hard to hold multiple themes at once or to notice that subtle cue while you’re listening. It can be even that sigh or it can be like a looking away. There could be a suggestion that maybe there’s something happening like they’re giving a clue around some suicidal ideation and we miss it, and so our attention really becomes inconsistent.

We look like we’re present. We can be nodding, reflecting and that, but we’re missing pieces of the client’s story. It’s not a lack of skill like I was saying, but it’s more of a lack of a cognitive bandwidth. It’s that change in our attention to what’s happening there.

I think of it like a light bulb or something. It’s like flickering on and off. Another example is really poor spotty wifi, right? Like sometimes it’s connect and then sometimes it drops. But we’re missing those shifts that are happening. So it does impact that way.

And then in terms of the emotional regulation when we’re tired we can go to, oh, this is a difficult client. We don’t say it out loud, but our nervous system is like just really close to the edge. And I think that clients can pick that up in us too. And so then it’s harder to just, say neutral and empathetic and compassionate, especially again with more challenging clients that really have intense material. And so when we hear how a client’s responding, it can make us feel frustrated or threatened when we’re overtired.

And also we can become more impulsive. Sometimes try to push through with an intervention that we wanna do or the client’s giving signals that they’re not ready yet for it. And so it’s struggling there to hold the boundaries. Or we can get stuck in indecision. Where do we go next? What do we do with this? So we’re physically showing up for our work, but we’re not showing up in our full capacity. And that’s not moral failing per se. This is a nervous system issue and not having that capacity.

That’s a really great way to conceptualize, what’s happening. And I know that there’s probably some listeners thinking, okay sleep changes from time to time. I have clients to see. Do I need to cancel my sessions every time, I have a bad night’s sleep? So from an ethical point of view, when does being tired cross a line into something more concerning where, we really have to self-reflect, am I capable or have the capacity to be able to work with my clients today?

Yeah, that’s a really important point because we all get tired. Absolutely. Fatigue in and of itself is not really an ethical issue. It shows that we’re human is part of being human. I’ve even have said to clients sometimes, oh. I’m tired today too. We can share that with the client to a certain extent.

I think the ethical line gets crossed when our tiredness starts to impair our judgment or our attention, or the emotional regulation piece that I was talking about. It’s not just when someone feels exhausted. The research shows that after an extended length of wakefulness, our cognitive functioning can really look similar to having alcohol in our system, so we would never knowingly practice while we are intoxicated. And so the concern comes in when the fatigue is reaching that sort of level of impairment, it becomes concerning when fatigue is leading to unsafe clinical decisions. Missing an important cue or misjudging a risk. So perhaps, there’s child abuse that might have to be reported and it’s oh like I don’t wanna hear that. And almost tuning out for that. And I think that struggle can happen with those types of dilemmas that need to be addressed in that moment.

For me, and what I would suggest to, therapists that I supervise and such is that missing time. Like when I was talking to my team, they told me something and then I miss that, and so they had to repeat it or that type of thing. So when you see a major flag of missing time. It’s realizing that you’ve lost part of the conversation or you zoned out without that sort of awareness. Because what can be happening is what they call micro sleeps. So when we’re lacking with sleep, our brain will actually take two or three seconds. Where it does this episode where it shifts into a sleep stage, but our eyes are actually still open and it only happens for two or three seconds. But in that space, that’s where we are zoning out. And it’s involuntary. So when it processes into ethically being concerning is when you’re starting to notice that. Going back to that dimming light bulb and that example, tiredness could be, that dim light bulb. Things are harder to see, but you can still function. You’re still seeing it. But when it crosses the ethical line, it’s like the circuit breaker has tripped. So the power has gone out. You’re still present, but the systems that you’re relying on for your judgment and regulation, they’re not online. So chronic sleep disruption is also a strong predictor of depression, anxiety, and substance use.

So noticing sleep issues early isn’t just about today’s session or what’s happening in the therapist room is also about that long-term professional sustainability.

I am reflecting on when I first finished my undergrad and I was working three casual jobs. Now, this is probably a little bit different than working as a therapist, but I worked as, crisis intervention and I did 24 hour shifts quite frequently. Actually, one time it was 36 hours. Sometimes I had to do it mandated, but sometimes I actually left one job and went to another job.

So some was my own choice, but some was mandated to stay because in certain scenarios you can’t leave until you have someone to relieve you. And as you were speaking, it really made me think about a few different scenarios. There was one time because we used to work overnights and it was non sleep overnight, so we had to stay awake, that I was awake and the clock was like 5:00 AM then I was still awake and then it was six and I don’t know where the time went. My eyes was open. So that’s using a really great example of I obviously had to have went into a micro sleep at that point.

And, again, if there was a client. Now I will say there was no clients, they were all in bed at this point, but if there was a client present or if something had happened during that time me being in a micro sleep wasn’t really an effective way of being. And I think when we think of some of the roles, especially like early in our careers, we may not necessarily have a therapist job that’s typically nine to five or so forth. And if we’re in some of these roles that mandate, 24 hour shifts and things like that.

It’s understanding kind of the impacts. And I think this could be like a whole different episode and we won’t go too far down this rabbit hole, but I think it’s then our professional ethics versus our organizational requirements. Like you can’t leave your job, ’cause you have clients there unattended. But again, this is a whole side conversation, but I think when we’re thinking about some of this, it’s really thinking about, even though it’s almost normalized in some of our professions that it’s okay to work 24 hour shifts. It’s not really.

Yeah, those are really good points and it can show up in different ways depending on the nature of your work, whether you’re in private practice and have that ability to say, Hey, this is almost a sickness . I’m not in my best. Or in a situation where you’re working as a social worker in a group home or that type of thing that you’re talking about.

And you’re right. It speaks to my story and how I got really interested about sleep well because my journey of compassion fatigue and burnout. There’s the micro level of the person, the effective use of self, like we’ve talked about earlier, and then the larger macro level of what is expected, a lack of resources having to do so much more with so much less.

And I, to make a long story very short, became, quite sick. And part of the root of that was my own compassion fatigue and burnout and vicarious trauma from the work that I was doing. And nobody trained me in my program and I think now we’re having better conversations, but this was, 12 years ago or so, and it took a long time to get back to being my old self. And so I did a lot of research and learning what are those supports and what are those things I need to have as part of my structure, part of my sort of rhythm of life to have that sustainability for the long haul. And sleep is a very cornerstone piece of that I learned because if I can root myself in my sleep, that takes care of so much, which makes the other pieces of it fall into place, which then creates the sustainable factor. So yeah, it’s a big conversation.

Absolutely. So now I’m thinking of the supervisors listening to this episode and potentially they, feel like that one of their supervisees might be lacking sleep. Even if the supervisee hasn’t said anything. First, what are some of the signs that they should be looking forward to determine this, but then also what is the supervisor’s responsibility when they notice it?

Yeah. So I think it’s important to identify that a supervisor’s responsibility isn’t to necessarily diagnose what’s going on, but it’s when noticing the changes in the therapist they’re working with, the functioning or how a therapist creating space, and exploring what might be contributing to some of the challenges that a therapist is bringing into supervision, or if you’re, watching a video session of the therapist and what is it that they’re facing in their work and just, maybe seeing, the ball getting dropped on something or, where it’s almost like a little bit of a step back, what is it that is happening here?

And what supervisors will notice first isn’t necessarily going to be a lack of sleep, but it’s gonna be that change in the cognitive bandwidth or the emotional responsiveness that is showing there. And so a supervisee may seem scattered or they might have difficult tracking that clinical material like we talked about, or you might notice more that emotional reactivity with the clients and maybe not with the client, but within the supervision, like, why don’t they get it? Or, just a frustration.

And so if a supervisee is struggling in that way and you’re noticing that reactiveness or a lack of empathy, it doesn’t automatically mean that there’s a lack of skill or insight. It might be that their nervous system is under strain, and so the sleep piece of it is one that is very common that can often get overlooked as a contributor.

Ethically, I would say that the supervisor’s role is to approach this with curiosity rather than correction. So the question isn’t what’s wrong with you? Are you getting enough sleep? But like what’s happening that might be affecting your capacity right now? We’re obviously not responsible as supervisors for managing the supervisee sleep or the therapist or social workers sleep or their personal life, but we are responsible for addressing anything that may affect their competence, their judgment, and their client care.

And so when supervisors notice these signs early and can gently explore the possible contributors, including sleep, it can prevent more serious impairment later. And it also protects that client safety and it can support the therapist long term.

So I think that how you do that and how you can shift the conversation, say, curious about it is similar in a lot of ways to our work with clients in what we talked about that way. It’s gonna be important as a supervisor to stay grounded in what they’re observing in the therapist’s work. The changes in the focus or regulation or just something seems off here.

Rather than just jumping into an explanation or fixing it or teaching them. But it’s introducing and exploring one possible factor which could be sleep and such. So a supervisor might say something like, I’m noticing that it seems harder for you to stay grounded in the sessions lately. Sometimes things like sleep or overall stress can affect that. So I’m wondering if that’s part of what’s going on for you right now. So it just keeps the language as being like curious not accusing, but. Invitational to a conversation. It could be that the therapist will say, yeah, my 18 month old baby is teething, or, this is happening.

And it frames it more again, in that nervous system capacity. That being the issue rather than that personal responsibility or shame around that. We keep it in the. Physiological space of that. And then the encouragement then is that’s something to improve on work on if that’s a, talking to your doctor or going to a naturopath. But the supervisee has to be responsible for their sleep habits. We don’t wanna police that. I don’t wanna police that. And so it’s more keeping it on, is it affecting the client care? Because ultimately that’s what we have to be responsible for.

And it keep the space collaborative, I guess is what I’m trying to say. And just signaling that it’s really important to make sure that you have that effective use of self as the CRPO would say. How are you showing up in the therapy room? Are you fully present with the client? We are human, things happen. Sometimes that means it’s being intentional about getting to bed. Sometimes it’s about a bigger issue. And so just having these conversations is really important.

I love that. I think that’s very helpful for both supervisors, working with supervisees, but I think even for supervisees to hear, as you’re going through this as well.

So Pamela, you have a free assessment that you’d like to share. Can you tell us what it is and how it can help listener?

Yeah, I have a free assessment that I use both with therapists and also with my clients. It’s called a Better Sleep Self-Assessment. It’s an evidence-based, but non-diagnostic, is mainly a reflection tool, and it’s designed to help people just notice what are the patterns in their sleep in their stress, their routines, and that nervous system activation that can happen when we’re struggling in our sleep.

I think it’s important for me to say too, it is not a tool or an assessment for doing a diagnosis. It’s not sleep treatment and doesn’t determine if a person has insomnia. But it’s more around that awareness. And as a therapist or supervisor it can be helpful for just self monitoring. It can help to notice when sleep patterns may be interacting with that cognitive bandwidth or the emotional regulation. And it can also just show maybe what areas can be tweaked or worked on. And not having to have it take up time within the supervision.

So it just looks at sleep timing and falling or staying asleep. The daytime fatigue, what are the habits in the environment and what are other stress related factors? But what matters most isn’t just the one response but it’s the pattern that emerges and that awareness can be a really helpful first step.

I love that. So to sign up for Pamela’s Better Sleep Self-assessment, check out hopeharbour.kit.com/sleep-assessment

or you can simply scroll down to the show notes and click on the link.

Pamela, thank you so much for joining us on the podcast today to discuss when therapist fatigue matters and how it can impact our clinical practice.

Thanks.

And thank you everyone for tuning into today’s episode, and I hope you join me again soon on Your Clinical Supervisor’s Coach podcast.

Until next time, bye for now.