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03/18/2010 05:12 am ET | Updated May 25, 2011

Why Hasan Did It: Are Shrinks Really Crazy?

The tragedy at Ft. Hood reminded me of an extensive investigative piece I wrote for Psychology Today a few years ago. I'm reprinting it below. The whole article is relevant to the ongoing discussion about Maj. Hasan, but take an especially close look at the section entitled "Patients Can Really Ruin Your Day." It seems likely that religious and political factors are important in Hasan's case, but so is his profession....

Are Shrinks Really Crazy?

Originally published in Psychology Today

In 1899 Sigmund Freud got a new telephone number: 14362. He was 43 at the
time, and he was profoundly disturbed by the digits in the new number. He
believed they signified that he would die at age 61 (note the one and six
surrounding the 43) or, at best, at age 62 (the last two digits in the number).
He clung, painfully, to this bizarre belief for many years. Presumably he was
forced to revise his estimate on his 63rd birthday, but he was haunted by other
superstitions until the day he died -- by assisted suicide, no less -- at the
ripe old age of 83.

That's just for starters. Freud also had frequent blackouts. He refused to
quit smoking even after 30 operations to correct the extensive damage he
suffered from cancer of the jaw. He was a self-proclaimed neurotic. He suffered
from a mild form of agoraphobia. And, for a time, he had a serious cocaine
problem.

So much for the father of psychoanalysis. But are these problems typical for psychologists? How are Freud's successors doing? Or, to put the question another way: Are shrinks
really "crazy"?

I myself have been a psychologist for nearly two decades, primarily teaching
and conducting research. So the truth is that I had some preconceptions about
this topic before I began to investigate it. When, years ago, my mom told me
that her one and only session with a psychotherapist had been disappointing
because "the guy was obviously much crazier than I was," I assumed,
or at least hoped, that she was joking. Mental health professionals have access
to special tools and techniques to help themselves through the perils of
living, right?

Sure, Freud was peculiar, and, yes, I'd heard that Jung had had a nervous
breakdown. But I'd always assumed that -- rumors to the contrary
notwithstanding -- mental health professionals were probably fairly healthy.

Turns out I was wrong.

DOCTOR, style='mso-bidi-font-weight:normal'>ARE style='mso-bidi-font-weight:normal'> YOU FEELING OKAY?

Mental health professionals are, in general, a fairly crazy lot -- at least
as troubled as the general population. This may sound depressing, but, as
you'll see, having crazy shrinks around is not in itself a serious problem. In
fact, some experts believe that therapists who have suffered in certain ways
may be the very best therapists we have.

The problem is that mental health professionals -- particularly
psychologists -- do a poor job of monitoring their own mental health problems
and those of their colleagues. In fact, the main responsibility for spotting an
impaired therapist seems to fall on the patient, who presumably has his or her
own problems to deal with. That's just nuts.

Therapists struggling with marital problems, alcoholism, substance abuse,
depression, and so on don't function very well as therapists, so we can't just
ignore their distress. And ironically, with just a few exceptions, mental
health professionals have access to relatively few resources when they most
need assistance. The questions, then, are these: How can clients class=GramE>be protected -- and how can troubled therapists be helped?

THE ODD TREATING THE ID

Here's a theory that's not so crazy: Maybe people enter the mental health
field because they have a history of psychological difficulties. Perhaps
they're trying to understand or overcome their own problems, which would give
us a pool of therapists who are a hit unusual to begin with. That alone could
account for the image of the Crazy Shrink.

Of the many prominent psychotherapists I've interviewed in recent months,
only one admitted that he had entered the profession because of personal
problems. But most felt this was a common occurrence. In fact, the idea that
therapy is a haven for the psychologically wounded is as old as the profession
itself. Freud himself asserted that childhood loss was the underlying cause of
an adult's desire to help others. And Freud's daughter, Anna, herself a
prominent psychoanalyst, once said, "The most sophisticated defense
mechanism I ever encountered was becoming a psychotherapist." So it's only
appropriate that John Fromson, M.D., director of a
Massachusetts program for impaired physicians, describes the mental health
field as one in which "the odd care for the id." He chuckled as he
said this, but, as Freud claimed, humor is often a mask for disturbing truths.

These impressions are confirmed by published research. An American
Psychiatric Association study concluded that '"physicians with affective
disorders tend to select psychiatry as a specialty." (Curiously, the
authors presented this as their belief, "for a variety of reasons,"
without explanation.) In a 1993 study, James Guy, Ph.D., dean of the School
of Psychology
at Fuller Theological
Seminary, compared the early childhood experiences of female psychotherapists
to those of other professional women. The therapists reported higher rates of
family dysfunction, parental alcoholism, sexual and physical abuse, and
parental death or psychiatric hospitalization than did their professional
counterparts. And a 1992 survey of male and female therapists found that more
than two-thirds of the women and one-third of the men reported having
experienced some form of sexual or physical abuse in early life. Freud seems to
have been right about this one: The mental health professions attract people
who have suffered.

PATIENTS CAN REALLY RUIN YOUR style='mso-bidi-font-weight:normal'>DAY style='mso-bidi-font-weight:normal'>

So we're starting out, it seems, with a pool of well-meaning but slightly
damaged practitioners. Now the real fun begins.

Check out the numbers: According to studies published in 1990 and 1991, half
of all therapists are at some point threatened with physical violence by their
clients, and about 40 percent are actually attacked. Try to put this in
context. A special, intimate relationship exists between therapist and client.
So being attacked by a client is a serious emotional blow, perhaps comparable,
in some cases, to being a parent attacked by one's child. Needless to say,
therapists who are assaulted get very upset. They feel more vulnerable and less
competent, and sometimes the feelings of inadequacy trickle over into their
personal relationships.

Let's take this a step further. Imagine working with a depressed patient
every week, without fail, for several years and then getting a call saying that
your patient has killed herself. How would you feel? Alas, patient suicide is
another hazard of the profession. Between 20 and 30 percent of all
psychotherapists experience the suicide of at least one patient, again with
often devastating psychological fallout. In a 1968 hospital study,
psychiatrists reported reacting to patient suicides with feelings of
"guilt and self-recrimination." Others considered the suicide to be
"a direct act of spite" or said it was like being "fired."
Whatever the reaction, the emotional toll is great.

Virtually all mental health professionals agree that the profession is
inherently hazardous. It takes superhuman strength for most people just to
listen to a neighbor moan about his lousy marriage for 15 minutes.
Psychologists, of course, enter the profession by choice, but you can imagine
the effects of listening to clients talk about a never-ending litany of serious
problems -- eight long hours a day, 50 weeks a year. "My parents hated me.
Life isn't worth living. I'm a failure. I'm impotent. On the way over here, I
felt like driving my car into a telephone pole. I'll never be happy. No one
understands me. I don't know who I am. I hate my job. I hate my life. I hate
you."

Just thinking about it makes you shudder.

IT'S A ROUGH WORLD OUT THERE

Patients aren't the only source of stress for psychotherapists. The world
itself is pretty demanding. After all, that's why there are patients.

A number of surveys, conducted by Guy and others, reveal some worrisome
statistics about therapists' lives and well-being. At least three out of four
therapists have experienced major distress within the past three years, the
principal cause being relationship problems. More than 60 percent may have
suffered a clinically significant depression at some point in their lives, and
nearly half admitted that in the weeks following a personal crisis they're
unable to deliver quality care. As for psychiatrists, a 1997 study by Michael class=SpellE>Klag, M.D., found that the divorce rate for psychiatrists
who graduated from Johns Hopkins University School of Medicine between 1948 and
1964 was 51 percent -- higher than that of the general population of that era,
and substantially higher than the rate in any other branch of medicine.

These days, therapists face a major new source of stress: HMOs. Richard class=SpellE>Kilburg, Ph.D., senior director of human resources at Johns
Hopkins University

and one of the profession's leading experts on distressed psychologists, says
managed care is having a devastating effect: "Therapists are chronically
anxious. It's getting harder and harder to make a living, harder to provide
quality care. The paperwork requirements are enormous. You can't have a meeting
of practicing psychologists today without having these issues being raised, and
the pain level is rising. A number of my colleagues have been driven out of the
profession altogether."

No wonder Richard Thoreson, Ph.D., of the University
of Missouri
, estimates that at any
particular moment about 10 percent of psychotherapists are in significant
distress.

THE FINAL RESOLUTION

Bruno Bettelheim. Paul Federn.
Wilhelm Stekel. Victor Tausk.
Lawrence class=GramE> Kohlberg. Perhaps you recognize one or two of the names.
They're all prominent mental health professionals who,
like Freud, committed suicide.

All too often the stresses of work and everyday life lead mental health
professionals down this path. According to psychologist David Lester, Ph.D.,
director of the Center for the Study of Suicide, mental health professionals
kill themselves at an abnormally high rate. Indeed, highly publicized reports
about the suicide rate of psychiatrists led the American Psychiatric
Association to create a Task Force on Suicide Prevention in the late 1970s. A
study initiated by that task force, published in 1980, concluded that
"psychiatrists commit suicide at rates about twice those expected [of
physicians]" and that "the occurrence of suicides by psychiatrists is
quite constant year-to-year, indicating a relatively stable over-supply of
depressed psychiatrists." No other medical specialty yielded such a high
suicide rate.

One out of every four psychologists has suicidal feelings at times,
according to one survey, and as many as one in 16 may have attempted suicide.
The only published data -- now nearly 25 years old -- on actual suicides among
psychologists showed a rate of suicide for female
psychologists that's
three times that of the general population,
although the rate among male psychologists was not higher than expected by
chance.

Further studies of suicides by psychologists have been difficult to conduct,
says Lester, largely because the main professional body for psychologists, the
American Psychological Association (APA),
hasn't released any relevant data since about 1970. Why? "The APA
doesn't want anyone to know that there are distressed psychologists,"
insists University of Iowa
psychologist Peter Nathan, Ph.D., a former member of an APA
committee on "troubled" psychologists.

ALCOHOL style='mso-bidi-font-weight:normal'>AND style='mso-bidi-font-weight:normal'> ADDICTION

Wait, there's more. "Mental health professionals are probably at
heightened risk for not just alcoholism but [all types of] substance
abuse," reports Nathan. It's not surprising: Substance abuse is one of the
most common -- albeit destructive -- ways people deal with anxiety and
depression, and, as we've seen, mental health professionals have more than
their share.

Richard Thoreson's decades of research on alcoholism,
in fact, stemmed from his own problems with the bottle. "I began drinking
at a fairly early age," he says, "and I continued during my early
academic career. My life was organized around drinking. It had a very negative
impact on my family. At one point I resigned as president of an organization
because I was too shaky to speak before a group. I stopped drinking in 1969, at
which point I was drinking the equivalent of 16 ounces of whiskey a day."

In the 1970s, with the help of several colleagues, Thoreson
founded an informal group called Psychologists Helping Psychologists, which has
held open Alcoholics Anonymous meetings at the annual APA
convention ever since. This unofficial, all-volunteer group has helped hundreds
of psychologists over the years -- with no financial support from the APA.

ADDICTED TO THERAPY

"Some therapists," says James Guy, "expect to continue
practicing longer than the life expectancies in actuarial tables." But
with advancing age, impairment is almost inevitable. Explains Guy: "Lower
back pain becomes a problem. Failing eyesight and hearing make it difficult to
pick up on subtle nuances. Poor bladder control can make it difficult to sit,
and fatigue becomes a big factor."

Further complicating matters is that as therapists get older, more and more
of their intimacy needs and social support actually comes from their patients.
"Often, most of their waking hours are spent with clients, focusing on
emotionally laden material," notes Guy. "When that's the situation, it's
difficult for them to think about retirement. It's even difficult for them to
know when to take time off."

Many psychotherapists become, in effect, woefully addicted to their clients,
with no one offering them guidance or alternatives. In general, private,
independent practices -- often conducted out of the therapist's home -- put the
therapist at greatest risk, no matter what his or her age. Thoreson
adds that such practices have special appeal for therapists who don't want to
be seen by colleagues; the isolated practice is the ideal one for the alcoholic
or drug abuser.

DO THEY USE THEIR OWN TOOLS?

If therapists really have special tools for helping people, shouldn't they
be able to use their techniques on themselves? After all, the late behavioral
psychologist, B. F. Skinner, systematically applied behavioral principles to
modify his own behavior, and he ridiculed Freud and the psychoanalysts for
their inability to apply their "science" to themselves. University
of Scranton
psychologist John
Norcross, Ph.D., and his colleagues have studied this
issue extensively, with two major findings. First: "Therapists admit to as
much distress and as many life problems as laypersons, but they also claim to
cope better. They rely less on psychotropic medications and employ a wider range
of self-change processes than laypersons."

This sounds encouraging, but Norcross's second finding makes you stop and
think: "When therapists treat patients, they follow the prescriptions of
their theoretical orientation. But the amazing thing is that when therapists
treat themselves, they become very pragmatic." In other words, when
battling their own problems, therapists dispense with the psychobabble and fall
back on everyday, commonsense techniques -- chats with friends, meditation, hot
baths, and so on.

But aren't psychotherapists required to be in therapy at various points in
their careers, so that they get specialized help from their colleagues? Not so.
"People are shocked when they learn this isn't true," says Gary class=SpellE>Schoener, Ph.D., who directs The Walk-In Counseling Center
in Minneapolis, perhaps the
country's first and last free psychology clinic. "Lawyers are subjected to
more psychological screens than psychologists are."

Surveys do indicate that most therapists -- between 65 and 80 percent --
have had therapy at some point. However, except for psychoanalysts -- the
pricey, traditional Freudians you see more in movies than in reality --
psychotherapists are virtually never required to undergo therapy, even as a
part of their training.

Freud himself would be appalled by this. "Every analyst should
periodically -- at intervals of five years or so -- submit himself to
analysis," he said. Unfortunately -- and ironically -- many
psychotherapists are reluctant to seek therapy. In a survey by Guy and James class=SpellE>Liaboe, Ph.D., for example, therapists said they were
hesitant to enter therapy "because of feelings of embarrassment or
humiliation, doubts concerning the efficacy of therapy, previous negative
experiences with personal therapy, and feelings of superiority that hinder
their ability to identify their own need for treatment." Others are
hesitant to seek therapy because of professional `complications' -- that is,
they cannot find a therapist nearby whom they do not already know in another
context. Or they mistakenly believe, as many patients do, that seeking therapy
is a sign of failure.

"I worry," says psychologist Karen Saakvitne,
Ph.D., "about the implication that the therapists who are in therapy are
the ones who are impaired. They are the ones acting in their clients' best
interest. I'm more worried about the therapists who don't seek help."

WOUNDED THERAPISTS

Maybe there's an upside to all these problems among psychologists -- if,
say, a therapist needs to have experienced pain and suffering in order to
relate to his or her clients' pain and suffering. This "wounded
healer" concept is, I believe, woven into the fabric of the mental health
profession. When I served as chair of a university psychology department, I
helped evaluate candidates for our marriage and family counseling program. The
admission process -- interview questions, essays, and so on -- was structured,
albeit subtly, to screen out people who hadn't suffered enough. What's more,
I've heard colleagues express concern about the occasional student or trainee
who, through no fault of his or her own, came from an unbroken home.

Data supporting this idea, however, are hard to find. "There's no
evidence whatsoever that you need a history of psychological problems in order
to be a good therapist," insists John Norcross. "In some studies, in
the first few sessions only, [patients see] the wounded therapist as a little
more empathetic, but the effect doesn't last. Experience with pain can enhance
a therapist's sensitivity, but that doesn't necessarily translate into good
outcomes."

"I don't think therapists need to have had the same experiences as
their clients," adds psychologist Laurie Pearlman, Ph.D. "As long as
the therapist can feel those feelings, he or she can connect with
clients."

On the other hand, in 1989 psychologists Pilar class=SpellE>Poal, Ph.D., and John R. Weisz,
Ph.D., found that therapists who faced serious problems in their own childhood
are more effective at helping child clients talk about their problems, perhaps
because of greater empathy. That study, however, is practically the only one
that supports the wounded-healer hypothesis.

THERAPEUTIC ADVICE

So you've gotten into therapy because your life is falling apart -- and now
you have to keep one eye on your therapist just in case his or her life is
falling apart, too? Basically, yes. Like it or not, you, the client, are
probably carrying the major responsibility for spotting the signs of distress
or impairment in your therapist, especially if you're seeing an independent
practitioner. The current president of the California Psychological
Association, Steven F. Bucky, Ph.D., puts it this
way: "The truth of the matter is that unless someone complains about an
impaired therapist, there is no protection for the client."

Here are some tips for protecting yourself from impaired mental health
professionals, and, perhaps, in so doing, for helping them overcome their own
problems. Remember, therapists are people, too.

First, it's probably safer to bring your problems to a practitioner who
works in a group setting. Independent, isolated therapists are probably at
greatest risk for having undetected and untreated problems of their own. On the
other hand, therapists working for managed care organizations or working under
the gun of insurance companies are exposed to special constraints and stressors
that may limit their ability to help you.

Second, trust your gut. "If you get the feeling that there's a problem,
you shouldn't deny what your instincts are telling you," says class=SpellE>Kilburg. If, during your session, a little voice in your
head begins screaming, "This guy's eyes remind me of my college roommate's
when he was tripping on acid," don't be afraid to ask questions.

Indeed, any time your therapist shows clear signs of personal distress or
impairment, bring your concerns to his or her attention. (Ideally, do this on
the therapist's dime, after your session is over.) If you're uneasy about
raising the issue with your therapist, talk to one of his or her colleagues
about it. Or, consider finding a new therapist. If you think your therapist's
problem is serious and has the potential to do harm, report it to the
appropriate professional organization or licensing body (see below). You have
legitimate cause for concern if your therapist:

*shows signs of excessive fatigue, such as red eyes or
sleepiness.

*touches you inappropriately or tries to see you socially.

*smells of alcohol, or you see liquor bottles or
drug paraphernalia in the office.

*has trouble seeing or hearing.

*talks at length about his or her own current, unresolved problems. This is
known as a "boundary violation," and it's especially worrisome,
because it's often a prelude to a sexual advance. In fact, therapists who talk
about their own unresolved problems are more likely to make sexual advances
than those who actually touch their clients.

*has trouble remembering what you told him or her last week.

*is repeatedly late for sessions, cancels them, or misses them.

*seems distant or distracted.

For help locating the appropriate organization or board, call the relevant national organization. For psychologists, call the American Psychological Association at (202) 336-5000; for psychiatrists, call the American Psychiatric Association at (202) 682-6000. If your therapist is a marriage and family counselor, try the American Association for Marriage and Family Therapy at (202) 452-0109, and if your therapist is a social worker, try the National Association of Social Workers at (202) 408-8600.