The breakneck speed of working on an inpatient behavioral medicine team of an urban tertiary hospital is quite often both exhilarating and exhausting for clinical psychology doctoral students. There is an idiosyncratic rhythm to the workload, as new consults roll in or patients the service follows are readmitted to the hospital. The expectation for trainees often seems to follow the so-called rule of comedic improvisation: saying “Yes and …” to everything, such that you are accepting more tasks and then contributing to them in novel ways. The pace of inpatient hospital work maintains the impression that practicum days are non-stop work, and that any basic self-care—like excusing yourself to eat a granola bar—would be time better spent doing something “productive.” While many faculty and supervisors will talk about self-care, it is rarely demonstrated, modeled, or given time and space to happen. Self-care is frequently encouraged within the clinical supervision literature, in efforts to mitigate burnout and optimize a clinician’s long-term ability to provide quality care (Barnett & Cooper, 2009; Elman & Forrest, 2007). Underscoring the relationship between psychologist self-care and the ethical protection of patients, the American Psychological Association’s (APA) Advisory Committee on Colleague Assistance (ACCA) directly lists poor self-care as a reason why psychologists are vulnerable to occupational stress occurs (ACCA, 2006). To prevent occupational stress, the ACCA lists several suggestions that incorporate the principles of self-care, such as maintaining work-life balance and attending to spiritual and physical well-being. The ACCA also asserts that making and maintaining professional relationships in which modelling and having an open dialogue regarding the stresses of clinical work can occur are effective methods to protect oneself from occupational stress (ACCA, 2006).

Additionally, self-care has been emphasized as an ethical imperative for psychologists and trainees as written in the APA ethics code (APA, 2002; Barnett & Cooper, 2009). To this end, self-care is considered one of the competency benchmarks for trainees (Fouad et al., 2009). Language encouraging the utilization of supervision is embedded in the APA’s revised self-care competency benchmark and behavioral anchors (APA, 2011). For example, trainees are considered ready for internship when they “monitor issues related to self-care with [their] supervisor” (APA, 2011). Given the field’s general positive view of self-care, it is perhaps surprising that trainees feel unprepared about how to integrate self-care into their education and clinical work (Munsey, 2006). In one study, 85% of trainees reported not receiving educational materials about self-care in their programs, 63% reported that their programs did not sponsor self-care activities, and 59% reported that their programs did not promote self-care activities (Munsey, 2006).  In turn, there is an apparent disconnect between the understood value of self-care and the clinical supervision and support of trainees to build this developmental skill. Though researchers have advocated for the incorporation of self-care into graduate training (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012; Rodolfa et al., 2005), particularly through supervision (APA, 2011; Barnett & Cooper, 2009; Elman & Forrest, 2007), there are still barriers to self-care to address that may help bridge the gap between knowing the benefits to self-care and teaching those benefits. Education must be done regarding self-care, as psychology graduate students may not be aware of the risks professional psychologists face (Fuselier, 2004), such as burnout and work-life imbalance. Also, students may fear that faculty and peers would question their professional dedication should they engage in self-care behavior (ACCA, 2009; Norcross & Guy, 2007). To break down these barriers, Elman and Forrest (2007) argued that supervisors should express to their supervisees that self-care is just as respectable a practice as hard work. Elman and Forrest (2007), like Barnett and Cooper (2009), suggested that creating a culture of self-care is necessary beginning at the graduate school level, through modelling, teaching, and skill-building.

For this particular behavioral medicine service, noon is synonymous with self-care in the form of group lunch in the cafeteria. At 12:01 PM, the supervisor will stand at the front of the narrow row of desks where trainees chart. “What are we still doing here?” She will exclaim with a smile. “It’s time for lunch!” We all turn to her, nod in her direction with our eyes still glued to the computer screens, and state variations of, “Just one minute, I’m almost done this note!” The supervisor deepens her smile, and gently says, “The notes can wait until after lunch, it’s time to eat.” We all dutifully pend our notes, sign off the computers, and walk as a group with our supervisors to the cafeteria, where conversation turns from evidence-based strategies to what the lunch special is that day. The cafeteria is a strategic move by our supervisors, a common space where we can all gather, but also a public space to temper the urge to discuss confidential cases and continue to work. We instead focus our attention to discussing weekend plans and take turns showing pictures of pets on our phones to the group.

Our designated self-care time is not only encouraged, but always modeled and reinforced by supervisors. It replaces the nebulous concept of “engaging in self-care” into a tangible action and establishes both the precedent and habit of basic self-care activities. Self-care also seems to mitigate the exhaustion that often accompanies practicum days, as we return well-fed and hydrated to our computers to check the consult list. It is refreshing to have the externship culture support daily self-care, without sacrificing a demanding and high-quality training experience in an inpatient setting. Of note, this experience aligns with the extant literature on self-care, such that self-care enables high quality practice (Barnett & Cooper, 2009). Perhaps, if anything, the standardized self-care activities propel us further into the challenges of our clinical population and provide training experiences that support the development of competent clinicians.

An externship in a pediatric outpatient interdisciplinary specialty clinic shares many qualities with an inpatient medical setting, and is also a demanding training experience. In one such clinic that focuses on young children with failure to thrive (FTT), a condition with a multifactorial etiology that often includes medical and behavior variables, clinical recommendations were varied for the families with which we worked. Thus, no guidelines existed in the literature for assessing longitudinal adherence to such recommendations and outcomes related to FTT.

Given the clinic’s emphasis on evidence-based interventions, alongside the other healthcare providers on the interdisciplinary team, the clinic supervisors encouraged and supported the trainees in developing a quality improvement research project to assess adherence in the clinic’s population. While there is limited data on the supervision of trainees engaging in research, the generation and evaluation of research is also considered to be a core competency benchmark for trainees, including behavioral anchors of engaging in research activities during training (Falender et al., 2004; Fouad et al., 2009). This blends into another competency benchmark focused on the assessment and application of evidence-based strategies into clinical care (Fouad et al., 2009). Further, it emphasizes the importance of the trainee’s developing competency of integrating knowledge and skills in providing evidence-based clinical care (Falender et al., 2004). The FTT adherence research project was integrated into the clinic’s care, as it addressed the fundamental question of how to improve outcomes for a singular clinical population with diverse needs. And so, the adherence measure became interwoven into our clinical experiences, and in essence became a formal structure to ask about and assess adherence to recommendations for our families in order to provide personalized care.

Clinical supervisors often extended supervision to discuss research methodology as it was relevant to the project and provided consistent mentorship in the design and implementation of the research. This supervision worked to support the research competency benchmarks described above and is consistent with the supervisory role as proposed in supervision research (Falender et al., 2004; Fouad et al., 2009). The research study facilitated conversations during group supervision to probe our increasingly nuanced understanding of adherence in a complex pediatric population, and the clinical strategies we could use to assess these hypotheses. Were families and providers leaving a clinical encounter with the same expectations and understanding? Did families and providers place the same cultural value in ameliorating a behavioral or medical need? Did families have the social and financial resources to implement what the team had recommended? Do we think of adherence in pediatrics to involve only caregivers, or to describe the dynamic relationship between caregivers, their children, and their providers?

This opportunity highlighted the importance of understanding the theoretical and applied mechanisms of a given intervention to determine its evidence base and clinical utility. Engaging in the research project gave us as trainees the ability to develop our research skills related to our competencies as training clinicians. Further, it facilitated insight into the complementary relationship between clinical work and research, aligned with the professional development of externs who are pursuing clinical research careers.  

In sum, the supervisory experiences detailed above fostered enriching learning opportunities for trainees building competencies across diverse domains. As trainees, we feel strongly that these supervisory experiences have led to our academic and professional development. Future research should assess the utility of supervisors modeling and instituting self-care procedures in the self-care competency development of trainees, as well as investigating how research engagement may foster research literacy/evidence-based assessment competency development in trainees. The opportunities described in this paper underscore how supervisors who continually support self-care and research acumen are vital to the development of competent, compassionate, and critically-minded future clinical psychologists.

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Jennie David, Ph.D

Jennie David is a fifth year doctoral student in the Clinical Psychology program at Drexel University, working under the mentorship of Drs. Brian Daly & Doug Chute. Jennie earned her Psychology with Honors degree from Boston University in 2013, where she completed a thesis investigating medical decision-making characteristics of adolescent patients with chronic rheumatologic illnesses and their parents. She has worked in a variety of disease populations, including HIV, cardiac surgery, and juvenile idiopathic arthritis. Jennie is interested in medical decision-making, informed consent, and medical literacy in a pediatric trans-diagnostic chronic illness population, with a particular emphasis on adolescents transitioning to adult care. Jennie is currently completing her predoctoral internship at Neumours/A.I. duPont Hospital for Children.