Reading Navigation
Sustaining the practitioner, part one
Key points
- The closeness that lets this work reach deep material is the same closeness that moves load into the practitioner.
- Burnout and secondary traumatic stress are the names for what that load becomes when it is not discharged.
- Sustaining a practice begins at caseload and case selection.
- Recovery research identifies four experiences that reduce strain after demanding work: detachment, relaxation, mastery and control.
1. What the closeness makes possible, and what it costs
A dosing session can run eight hours or longer. The bond that can develop in days like that often holds more weight than the rapport built across weeks or years of therapy. It also forms quickly, catalysing the therapeutic relation, which hours of preparation sessions have already cultivated. By the time the medicine is taken, the client has agreed to set down a great deal of ordinary self-management in another person’s presence. Younger, vulnerable states surface readily in that condition and can stay for hours, and the practitioner is there for all of it.
That closeness is what allows this work to reach material that talk therapy alone may address slowly, or not at all. It is also the channel through which a practitioner can take on more than they can carry. The relational container article PsyStandard published describes the asymmetry involved, where the client moves and the practitioner stays steady. Holding steady and grounded across that timespan asks for more than physical stillness. It requires continuous attention to another person’s state alongside the self-regulation that keeps you available while that condition changes, and what it asks often does not end when the client goes home.
Three capacities determine whether that energetic and psychological weight accumulates, and with it the sustainability of long term practice: a way to regulate while the session runs, a way to release in the hours and days after, and a way to come back to yourself across the longer arc of a practice. Where these are missing, what has not been discharged risks carrying into the next session and, if left unchecked, can develop into burnout and secondary traumatic stress.
Clients are offered integration support as a matter of course, because everyone accepts that an experience needs somewhere to land. The practitioners who sat through those same experiences are generally left to process alone. Ingmar Gorman has written about this gap directly, and the principle is worth stating plainly: integration is for practitioners too. What follows applies to clinicians in regulated settings, to practitioners working outside them, and to retreat staff holding containers for days at a time.
2. What this work asks of the practitioner
A 50-minute session asks for attention that can be gathered and then released. A dosing session asks for attention that stays focused through a full working day or night, across stretches where nothing is required and prolonged periods where everything is asked. The practitioner tracks breathing, posture, affect and sound while saying very little for long periods, and that combination of vigilance and restraint is psychologically and energetically tiring in a way that physical activity is not.
Practitioners often describe what remains after a session as energetic residue, as the physiological ramifications of the session take their toll on the body. Long dosing days involve sustained sympathetic activation, continuous co-regulation, and empathy that recruits shared affective representations, whereby witnessing distress in a participant engages some of the practitioner’s own neurohormonal distress circuitry (Singer and Klimecki). Repeated activation without adequate recovery is what the allostatic load literature describes as cumulative “wear and tear on the body and brain” (McEwen). Nothing literally or physically passes from one nervous system to another, although what builds up is exposure, resonance and arousal that needs to be released.
What I notice in my own and colleagues’ practice is how easily attachment patterns can take hold in this work, and how readily our own material can resurface in response to what a client brings. The closeness reaches beyond the client’s early patterns and can activate the practitioner’s as well, and when it does, the practitioner is still the one expected to stay steady. Long hours, physical proximity or even touch, a client in an age regression state and a practitioner in a caregiving position are conditions under which familiar relational shapes assert themselves. Practitioners who have worked substantially on their own history are no less susceptible to the activation. They are just quicker to recognise it.
One form this takes is overidentification with outcomes, which Gorman names as a route into burnout. After a session that went badly you revisit the preparation, the dose, the music, the moment you spoke when you might have waited, and treat the result as a representation of your competence. That capacity for self-examination is part of what makes a practitioner careful. Left unheld, it becomes a standing charge against yourself. A second strain is particular to this field, since many practitioners came to the work through their own experiences of altered states, and those experiences carry meaning that professional language does not easily hold.
3. Regulate, release, return
The practices below are familiar, and none are complicated. What makes them work is that they are decided in advance and integrated into the working week rather than attempted when capacity is already low.
Before any of it, who you take on. Set and setting apply to the practitioner as much as to the client. Your own set is the state you arrive in across a month rather than a morning, and your setting includes how many medicine sessions sit in the calendar and what they are likely to ask. Knowing yourself in this work means knowing which clients and topics you may find more taxing than a colleague. Histories that resemble your own, clients whose way of attaching activates yours, cases in acute crisis needing more contact between sessions: each is manageable alone, but costly in unison.
The practical decision is about volume and resources made while the calendar is still empty, with a willingness to refer when a case sits on an edge you already know about. This concerns sequencing and capacity rather than screening out whole categories of people, since the same reasoning can be used to avoid work that is merely uncomfortable.
Regulate, while the work is happening. Arriving resourced means your own nervous system is grounded and settled before the client appears and you are clear on your professional intention for the day. An honest fitness check belongs here, with a real willingness to postpone, which only exists when the calendar and finances allow it.
During the session, breath and posture are the available regulators to help you re-attune in a turbulent session. Slow breathing at around six breaths a minute raises heart rate variability and builds the stress resilience needed across a long day. Most of this depends on detecting subtle bodily activations, and a long-standing meditation practice can help make that noticing more automatic.
Release, in the hours and days afterwards. Release means letting the body finish what it could not finish during the session. Activation builds while you hold still and stay attentive, and it stays in the system until something discharges it. Recovery research gives this more precision than practitioner language usually manages. Sonnentag and Fritz identify four practices to recuperate linked to lower exhaustion and fatigue after demanding work, and two belong here: psychological detachment and relaxation. Detachment is created by boundaried availability. If clients can reach you at any hour the working day never closes, so agree response times at the start and keep to them.
The practical forms to initiate relaxation are ordinary. A closing ritual marks the end for the practitioner as well as the client, and can be as simple as opening the windows, changing clothes and writing the notes, while documentation and journaling give the material a place outside your head. Protected recovery time matters more than any single practice, and back-to-back medicine days can remove it. Movement, somatic discharge and time outdoors can help rebalance a nervous system over time. Sauna has a straightforward mechanism behind it, since heat raises cardiovascular load and cold exposure brings a parasympathetic rebound. It reliably marks a physical end to a working day, which is its value here.
Return, across the longer arc. The other two recovery experiences are mastery and control, and both explain what practitioners misread as indulgence. Mastery means absorbing challenge in an unrelated domain, which is why learning an instrument or a language restores rather than drains. Control means authority over your own time, which is why a calendar someone else fills depletes you, however reasonable each booking looks. A regular meditation practice builds interoceptive awareness and supports the distinction between compassion and empathic distress that Klimecki and Singer describe as trainable. Bodywork addresses the vigilance long sessions can leave in the shoulders, jaw, hips and knees.
Who holds you, and how much. Your own therapeutic space is a working necessity for the reasons above, since material that surfaces in sessions needs somewhere of its own to be addressed. Three layers sit around it. Supervision carries professional accountability and the cases involving risk. Intervision carries peer reflection with people who see your work across months. Friends and partners carry you rather than the material, and that limit is worth stating plainly, because they are often asked to carry material they never agreed to and are not trained to handle. Disclosing to loved ones can put stress on the relationship and breaches what a client shares in confidence. Each of these has its place, and keeping a clear line between the professional containers and the personal ones lets release land where it belongs and a practice continue over years.
4. What accumulates, and what it is called
Burnout, as Maslach described it, is exhaustion, cynicism and reduced efficacy, and ICD-11 lists it as an occupational phenomenon rather than a medical condition. Secondary traumatic stress, in Figley’s formulation, is trauma-like symptoms arising from indirect exposure: intrusive imagery, avoidance, hyperarousal. Vicarious trauma, as McCann and Pearlman describe it, is slower, a cumulative shift in what you believe about safety, trust and meaning. Against these sit vicarious resilience, described by Hernández and colleagues, and compassion satisfaction, measured within Stamm’s ProQOL. Both are real psychological states, yet neither are protective on their own.
When the practices above slip, the effects run two ways. You experience sleep disruption, numbness, and cynicism about clients you previously cared about, which is the mental distance Maslach and ICD-11 both name as a core feature. Clients meet thinner attunement, missed risk signals, rushed integration, and boundaries that move without anyone giving consent to adjust them.
Research with psychotherapists has associated higher empathy and higher vicarious trauma with higher burnout, and the same study found that the degree supervision had a significant effect on predicting burnout. The practitioners most able to meet clients closely carry the heaviest load. Evidence specific to psychedelic practice remains thin, and most of the above is extrapolated from trauma therapy, where session lengths and intensities differ considerably.
5. What a sustaining practice has in place
The following is a description rather than a standard, drawn from what holds up across years rather than months.
- Caseload and recovery. A limit on medicine sessions in a given month, with recovery time between them, decided in advance.
- Daily practices that hold without effort. Meditation, yoga or an equivalent embodiment practice, and a reliable physical reset after long sessions.
- Supervision that includes your own integration, with someone experienced in altered states, at a rhythm matched to your caseload.
- A peer group that meets consistently, where the same people see your work across months.
- People who understand the work, so debriefing does not fall to someone who cannot hold it.
- Your own therapeutic process, alongside body-based support for what sessions leave in the body.
- A way of noticing early. Periodic self-assessment, for example the ProQOL, and a decision made in advance about what would make you pause your practice and whom you would tell, or seek support from.
- Somewhere for clients to go. A referral network and a continuity plan if you need to stop, which matters most to the people who would otherwise be left mid-process.
That list is straightforward to write and considerably harder to hold, particularly in the years when a practice is still being built. Part two takes up why it slips, what the slipping costs the people in your care, and what catches the drift before a practitioner can see it themselves.
Sources
Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.
Gorman, I. Burnout and burnout therapy in the psychedelic renaissance: A therapist’s survival guide. https://www.ingmargorman.com/resources/burnout-and-burnout-therapy-in-the-psychedelic-renaissance-a-therapists-survival-guide
Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46(2), 229–241. https://doi.org/10.1111/j.1545-5300.2007.00206.x
Klimecki, O. M., Leiberg, S., Ricard, M., & Singer, T. (2014). Differential pattern of functional brain plasticity after compassion and empathy training. Social Cognitive and Affective Neuroscience, 9(6), 873–879. https://pmc.ncbi.nlm.nih.gov/articles/PMC4040103
Laukkanen, J. A., Laukkanen, T., & Kunutsor, S. K. (2018). Cardiovascular and other health benefits of sauna bathing: A review of the evidence. Mayo Clinic Proceedings, 93(8), 1111–1121. https://pubmed.ncbi.nlm.nih.gov/30077204/
McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149. https://doi.org/10.1007/BF00975140
McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338(3), 171–179. https://doi.org/10.1056/NEJM199801153380307
Singer, T., & Klimecki, O. M. (2014). Empathy and compassion. Current Biology, 24(18), R875–R878. https://doi.org/10.1016/j.cub.2014.06.054
World Health Organization. (2019). Burn-out an occupational phenomenon: International Classification of Diseases. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
