Editors’ Note: As a reminder, please send your psychotherapy research-, practice-, and training-related Ethics questions to Apryl.Alexander@du.edu. Please note that questions may be selected by Dr. Alexander for inclusion in Psychotherapy Bulletin or on the SAP website/social media platforms at her discretion, and not all questions may be answered. In addition, information provided to Dr. Alexander and SAP in this context is for the purpose of furthering public knowledge and discourse around ethical issues and will not be kept confidential.
Clinical Impact Statement: Psychologists need self-care strategies, too! Creating a self-care plan can ensure psychologists are practicing ethically and live healthy, happy lives.
I recently attended a faculty awards ceremony at my university. The faculty award recipients, along with the audience, watched videos of remarks and comments from the awardees’ students and colleagues. All of the remarks were expectedly heartwarming and lovely; however, I could not help to notice a trend in each of the videos. Nominators remarked on how the awardees answered e-mails late into the night or very early in the morning, met with students after normal business hours to accommodate to student work schedules, and made jokes about how the professor likely never slept. There was one remark about the likely personal sacrifices the awardee made (i.e., missing family events/milestones) in order to do their job. Although I learned of all my colleagues’ amazing work and dedication to their students’ learning, success, and excellence, I left feeling some sorrow in thinking about my colleague’s well-being and concerned about the messages we give to students and other rising professionals.
The role and expectations of psychologists, regardless of work settings, are rising. In our work, we routinely discuss work-life balance and self-care, but do we engage in appropriate self-care tactics ourselves? As we approach the winter holiday season, we’re busy worrying about our year-end to-do lists, upcoming activities for the new year, and all that goes on in our personal lives. Entering the new year is a perfect time to think about engaging in a better self-care routine.
Stress Versus Burnout
Providing psychotherapy often involves hearing about client’s stress, difficulties, and/or trauma. Compassion fatigue and vicarious trauma can arise through this work. Compassion fatigue is when individuals suffer as a result of working in a helping role, while vicarious traumatization is when therapists are impacted by working with individuals who have experienced trauma (Rothschild & Rand, 2006). Vicarious traumatization occurs when professionals are affected by their clients’ traumatic experiences. Repeatedly hearing about clients’ traumas can take its toll on some clinicians. Clinicians may experience symptoms similar to those of their clients such as physiological arousal, depression, and anxiety. Compassionate fatigue can result in physical symptoms, such as chronic exhaustion and fatigue, insomnia, headaches, loss of physical agitation or retardation, and frequent sickness (Mendenhall, 2006). Clinicians must find ways to distance themselves from their clients’ stories and develop their own coping skills to deal with the stories. When I worked for a treatment program providing group therapy to children and adolescent sexual abuse survivors, we made it a routine to have debriefing meetings for 20 to 30 minutes after sessions to have a process group about the difficult content (and successes!) that came up in sessions. It is important for clinicians to monitor their own well-being and engage in effective self-care—whether this is through continued supervision, team consultation, or own personal therapy.
In severe cases, clinicians may experience professional burnout. Burnout is the result of job stress stemming from the numerous emotional hazards of the profession. It affects most mental health workers at some point in their career. Signs could include turning in items late, overbooking your schedule, calling out sick from work more often, and becoming irritable with colleagues and clients. Maintaining a healthy work-life balance by developing a support network, both personal and professional, is important in reducing burnout. Therefore, it is important for mental health care professional to maintain self-care regimen while providing help to others. Continued professional supervision, consultation, and debriefing meetings can be used in order to deal with thoughts and feelings associated with burnout.
The work demands of psychologists across different contexts are constantly growing. Expectations for clinical practice, administrative work, supervision, research and program evaluation, training/teaching, and mentoring are all becoming the standard for practicing psychologists. In fact, younger psychologists are reporting more burnout than older psychologists and burnout tends to decrease with age (Dorociak, Rupert, & Zahniser, 2017; Rupert, Miller, & Dorociak, 2015). Navigating professional boundaries can be challenging for professionals who feel the need to keep up with these increasing demands. In addition to work demands, personal and familial demands compounded with work demands can lead to burnout. According to a survey of APA graduate students and early career psychologists, nearly half reported experiencing financial stress and delaying personal milestones (i.e., marriage, having children, buying a home) due to accumulated debt (Doran et al., 2016).
I’ve heard the phrase, “‘No’ is a complete sentence.” It’s direct. It’s assertive. Demographic and identity factors can also influence how individuals set boundaries and engage in self-care. Early career professionals have difficulty finding balance in taking on activities to push forward their careers while navigating the transitional challenges described earlier. In my opening example, many of the awardees were women. In addition to their work lives, we know from the literature that women often have a “second shift” when it comes to taking care of household tasks and parenting after working a full day; though more recent research indicates a rise in more egalitarian roles in the household. Underrepresented groups, such as Professionals of Color and LGBTQ+ professionals, are often loaded with additional work given their identity status. For instance, if there is only one Latinx psychologist on a treatment team, there may be additional pressure from administrators to take on more clients of Latinx identity (rather than train current staff or provide additional translators) or engage in additional service work to create a more inclusive team. The psychologist may feel unable to say no, leading to an increase in role obligations. Systems must be challenged to address the added burdens on these groups in order to reduce the likelihood of burnout.
Connecting to Ethics
Why is self-care an ethics issue? As described above, burnout and vicarious/secondary victimization can impact our well-being and professional competence. Burnout increases one’s risk for professional impairment (Bamonti et al., 2014). Many scholars have described self-care as an essential ethical concern (Barnett, Baker, Elman, & Schoener, 2007; Barnett, Johnston, & Hillard, 2006; Rupert & Dorociak, 2019). Self-care is discussed as a benchmark for clinical training of graduate students (Fouad et al., 2009). Although graduate school presents many exciting opportunities, graduate education in psychology includes many stressors, including financial hardships, relocations, increased roles and responsibilities, and other life milestones (Ayala & Almond, 2018; Zahniser, Rupert, & Dorociak, 2017). Over 70% of graduate students report experiencing a stressor that interferes with optimal functioning (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012); however, in a sample of 177 clinical psychology doctoral programs, only 8.4% of programs referenced self-care in the general departmental handbook and only 24.8% included a reference in their clinical psychology handbook (Bamonti et al., 2014).
In the American Psychological Association (APA)’s 2017 Ethical Principles of Psychologists and Code of Conduct (Code of Ethics), self-care is not explicitly discussed in the guidelines. Of the general principles, self-care should be considered in Principle A: Beneficence and Nonmaleficence, which reads,
In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research … Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. (p. 3)
In order to provide adequate care to others, we must take care of ourselves. Self-care ensures unintentional harm is not done to our clients. Additionally, Standard 2.06 (Personal Problems and Conflicts) notes, “When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties” (APA, 2017, p. 5). The standard also discusses not engaging in activities where there is an increased likelihood of personal problems interfering with a person performing their job in a competent manner. Thus, psychologists should make efforts to maintain their own psychological health by being cognizant of their own health and well-being and seeking their own mental health care, if needed.
What Is Self-Care?
There are dozens of pop psychology and self-help books that describe tools for self-care. Spa days, bubble baths, walks, red wine and chocolate…many are superficial, and some are insensitive to financial restraints. A student once approached me after a holiday weekend and said, “You would be so proud of me! I engaged in self-care. I got a haircut and watched a movie.” Both of those things are satisfying. Perhaps relaxing. However, I questioned whether this was the actual self-care the student needed at the time given their disclosure of other personal struggles. Their conceptualization of self-care was likely restricted and unhelpful in meeting their true needs.
Self-care has been described as “a multidimensional construct broadly defined as an ongoing commitment to a healthy lifestyle comprised of multiple components that include actions to promote one’s health, exercise, nutrition, social support, stress management, and self-actualization” (Ayala, Ellis, Grudev, & Cole, 2017, p. 19). In a study examining self-care activities of women graduate students, cluster analysis revealed six distinct type of self-care activities: physical wellness (i.e., healthy cooking, exercise, regular medical checkups), relaxation and stress management (i.e., taking breaks or days off, getting enough sleep), hobbies (i.e., listening to music, reading for fun), interpersonal relations (i.e., spending time with loved ones, monthly outings, maintaining contact with friends and family), self-compassion (i.e., meditation, mindfulness, positive self-talk), and outdoor recreation (i.e., time spent outdoor, exploration, travel) (Ayala & Almond, 2018). These are all important domains to consider when developing your own personal self-care plan for the new year.
I am not an expert on self-care. My colleagues and friends could tell you and are likely making comments about me writing this article, as they read it (fortunately humor is a large part of my self-care). The aim is to challenge myself and others to do better. I hope collectively as colleagues and friends, we can think of ways to assist each other in self-care activities and prioritize them as a means of protecting ourselves personally and professionally in terms of competence and ethics.
Cite This Article
Alexander, A. (2019). More than bubble baths and wine: Finding actual self-care. Psychotherapy Bulletin, 54(4), 10-14.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/
Ayala, E. E., & Almond, A. L. (2018). Self-care of women enrolled in health service psychology programs: A concept mapping approach. Professional Psychology: Research and Practice, 49(3), 177-184. doi: 10.1037/pro0000190
Ayala, E. E., Ellis, M. V., Grudev, N., & Cole, J. (2017). Women in health service psychology programs: Stress, self-care, and quality of life. Training and Education in Professional Psychology, 11(1), 18-25. doi: 10.1037/tep0000141
Bamonti, P. M., Keelan, C. M., Larson, N., Mentrikoski, J. M., Randall, C. L., Sly, S. K., … McNeil, D. W. (2014). Promoting ethical behavior by cultivating a culture of self-care during graduate training: A call to action. Training and Education in Professional Psychology, 8(4), 253-260. doi: 10.1037/tep0000056
Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38(6), 603-612. doi: 10.1037/0735-7028.38.6.603
Barnett, J. E., Johnston, L. C., & Hillard, D. (2006). Psychotherapist wellness as an ethical imperative. In L. VandeCreek & J. B. Allen (Eds.), Innovations in clinical practice: Focus on health and wellness (pp. 257-271). Sarasota, FL: Professional Resources Press.
Doran, J. M., Kraha, A., Marks, L. R., Ameen, E. J., & El-Ghoroury, N. H. (2016). Graduate debt in psychology: A quantitative analysis. Training and Education in Professional Psychology, 10(1), 3-13. doi: 10.1037/tep0000112
Dorociak, K. E., Rupert, P. A., & Zahniser, E. (2017). Work life, well-being, and self-care across the professional lifespan of psychologists. Professional Psychology: Research and Practice, 48(6), 429-437. doi: 10.1037/pro0000160
El-Ghoroury, N. H., Galper, D. I., Sawaqdeh, A., & Bufka, L. F. (2012). Stress, coping, and barriers to wellness among psychology graduate students. Training and Education in Professional Psychology, 6(2), 122-134. doi: 10.1037/a0028768
Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M. B., …Crossman, R. E. (2009). Competency benchmarks: A model for understanding and measuring competence in professional psychology across training levels. Training and Education in Professional Psychology, 3(4S), S5-S26. doi: 10.1037/a0015832
Mendenhall, T. J. (2006). Trauma-response teams: Inherent challenges and practical strategies in interdisciplinary fieldwork. Families, Systems, & Health, 24(3), 357-362.
Rothschild, B, & Rand, M. (2006). Help for the helper: The psychophysiology of compassion fatigue and vicarious trauma. New York, NY: Norton.
Rupert, P. A., & Dorociak, K. E. (2019). Self-care, stress, and well-being among practicing psychologists. Professional Psychology: Research and Practice, 50(5), 343-350. doi: 10.1037/pro00000251
Rupert, P. A., Miller, A. O., & Dorociak, K. E. (2015). Preventing burnout: What does the research tell us? Professional Psychology: Research and Practice, 46(3), 168-174. doi: 10.1037/a0039297
Zahniser, E., Rupert, P. A., & Dorociak, K. E. (2017). Self-care in clinical psychology graduate training. Training and Education in Professional Psychology, 11(4), 283-289. doi: 10.1037/tep0000172