Introduction

Having an effective self-care plan in place can help ameliorate the hazards of our profession and enhance our therapeutic effectiveness. In this article, we’ll explore some of the research findings on impairment and examine a self-care model you can utilize in your own practice. Reflective questions (Alterman, 1998) have been included in each section to stimulate your thinking about this important topic.

Hazards of the Profession

Therapy is often a grueling and demanding calling. The literature points to moderate depression, mild anxiety, emotional exhaustion, and disrupted relationships as the common residue of immersing ourselves in the inner worlds of distressed and distressing people. Confidentiality, isolation, shame, and additional considerations lead us to over-personalize our own sources of stress, when in reality they are part and parcel of the common world of psychological work (Norcross, 2000).

The unique hazards of the profession can be grouped into five broad categories according to Kramen-Kahn & Hansen (1998):

• Business-related problems (e.g., economic uncertainty, record keeping)
• Client-related issues (e.g., suicidal threats)
• Personal challenges of the psychotherapist (e.g., constant giving, caring cycle)
• Setting-related stressors (e.g., excessive workload)
• Evaluation-related problems (e.g., difficulty evaluating client progress)

Alterman (1998) describes difficulties for the therapist in private practice. She noted the emotional demands of the work, the occasional triggering of the therapist’s own issues within the therapeutic relationship, the need to maintain hope and faith and instill both in the client, the lack of reinforcement, difficulty leaving work at the office, the constancy of the emotional intensity of the work, and the experience of engaging with others in the depths of their despair as some of the significant hazards of our work.

Reflective questions:

• Which aspects of the profession necessitate self-care?
• What are some of the emotional rigors of the work that come to mind for you?

Research Findings on Impairment

In a recent study, Mahoney (1997) conducted a survey of 325 mental health professionals attending a conference on brief therapy in San Francisco and found therapists reporting a host of problems, such as:

• 43% irritability or emotional exhaustion
• 44% insufficient or unsatisfactory sleep
• 42% doubts about their own therapeutic effectiveness
• 38% had concerns about the size/severity of their caseload
• 38% problems in their intimate relationships
• 35% episodes of anxiety or depression

In their study, Sherman and Thelen (1998) sampled 1000 randomly selected APA psychologists who indicated mental health service as their primary occupation. Respondents indicated the following stressors:

• 72% work with difficult clients
• 68% too much paperwork
• 54% uncertainty regarding best intervention for a client
• 45% counter-transference issues
• 42% insufficient income

Since 1985, research has consistently shown these types of distress among therapists. The top five sources of distress over this period include relationship difficulties (38-82%), depression (25-76%), job stress (33-72%), irritability and exhaustion (33-43%), and doubts about therapeutic effectiveness (42%). Wood, Klein, Cross, Lammers, & Elliott (1985) also found that 40% of psychologists are aware of colleagues whose work is affected by the use of drugs and 60% of psychologists are aware of colleagues whose work is affected by depression or burnout.

Reflective questions:

• How were you prepared for the emotional rigors of the work?
• What factors do you believe interfere with clinicians’ routinely employing good self-care?

Effects of Impairment and Barriers to Treatment

Common behavioral patterns that signify impairment, as identified by Margison (1997) include social isolation, neglecting meal breaks, and putting clients’ needs first. Impairment can lead to poor clinical judgment, increased risk of ethical breaches, boundary violations, and inappropriate emotional involvement with clients (Sherman, 1996; Faunce, 1990; Porter, 1995). An unfortunate fact among therapists is the sense of stigma that prevents some from seeking help for their impairment. Carroll, Gilroy, & Murra (1999) found thatherapists feel judged and ostracized by colleagues who learned of their depression.
Wash, Nichols, & Comack (1991) found that most psychotherapists were reluctant to use their colleagues for personal support at work because they believed they would be stigmatized for their problems and perceived by their colleagues as untrustworthy. In spite of these difficulties, Norcross (2000) notes that more than 50% of psychotherapists participate in psychotherapy after their training program is complete, and that more than 90% of therapists receiving psychotherapy rate the outcomes very positively along a number of dimensions (for example, enhancing their own clinical effectiveness).

Reflective questions:

• What would you say is the general attitude clinicians have toward their own self-care?
• What do you hope will be the standards for clinicians’ self-care practices ten years from now?

A Self-Care Model

A comprehensive self-care model spans several conceptual levels and includes a broad direction, reflected in acknowledgement of your deeply held values and personal mission, self-care strategies that provide broad guidance across situations, and specific self-care techniques that you use every day.

Your self-care plan should begin with reflection on your personal values and keep you connected to your purpose. These values guide your life and your work, and culminate in a personal mission statement. For example, the values of freedom, vitality, authenticity, and growth might coincide with a personal mission statement “to practice psychotherapy with compassion, dignity, and skill in order to promote growth in clients.”

Intermediate (between specific techniques and broad vision) strategies serve a guiding role in applying self-care principles across situations, and serve to support your higher mission and values. Some of the strategies, derived from Prochaska’s Transtheoretical Model of Change, you might consider are:

• Self-awareness: increasing information about yourself through consciousness-raising activities that facilitate the development of insight, spiritual growth, etc.
• Counter-conditioning: consider alternate ways of being different from the ways therapists are conditioned to be in the world. For example, consider a “My Greatest Moments in Therapy” journal to complement the common standard of focusing exclusively on solving client problems and treatment difficulties. Consider exercise to counter the effects of sitting most of the day.
• Self-liberation: make the choice to change and take personal responsibility for the self-care program you want. Acknowledge and accept the burden to replenish yourself both professionally and personally.
• Appreciate the rewards: refocus on the rewards associated with clinical work that bring you life and vitality. Look for ways to create a greater sense of freedom and independence in your work.

Carroll, Gilroy, & Murra (1999) have proposed a four part model of self-care techniques. Having specific techniques that you utilize in each area of the model provides for a self-care plan that is both comprehensive and rejuvenating.

• Intrapersonal Work: the focus of this part of the model is on increasing your self-awareness. Some specific techniques you might utilize could be participating in activities that increase your sense of spirituality, noticing how your values are reflected in your work and your life, scheduling time to reflect on your self-care plans, understanding where you are developmentally as an adult or as a practitioner, doing personal journaling, or participating in your own therapy.
• Professional Development: the focus of this part of the model is to continue to develop and renew as a clinician. Some specific techniques you might utilize could be attending case consultations, completing your continuing education units in classes that are interesting or altogether different from anything you’ve tried before, serving in your local association, connecting or serving in your local community, or developing your own continuing education courses.
• Physical and Recreational Activities: the focus of this part of the model is to have some fun with activities that are not work-related. You might enjoy an exercise program, vacations and travel, hobbies or other activities, taking time off for no specific purpose, reading, etc.
• Interpersonal Support: the focus of this part of the model is to maintain healthy relationships that support your well-being. Maintaining a healthy relationship with your partner, family, and friends can serve you well in difficult times. You might spend time with family and make time for good friends, including close relationships with peers who support you and your work.

Research has demonstrated that clinicians utilize a number of self-care techniques in their personal selfcare plans. Kramen-Kahn and Hansen (1998) surveyed 700 psychotherapists from a stratified, national random sample of the National Register regarding their coping strategies. The percent endorsing specific career sustaining behaviors are as follows:

• 82% maintain a sense of humor
• 75% perceive client problems as interesting
• 71% feel renewed from leisure activities
• 70% use leisure activities to relax
• 68% maintain objectivity about clients
• 62% use solitary renewing activities

Mahoney (1997) found that mental health professionals endorsed previous year self-care activities in a wide variety of areas:

• 87% engaged in a hobby or reading for pleasure
• 84% taken pleasure trips or vacations
• 85% attended movies, artistic events, or museums
• 78% engaged in physical exercise
• 64% participated in peer supervision
• 50% played recreational games
• 52% practiced meditation or prayer
• 43% engaged in volunteer work for a worthy cause
• 28% been a client in personal therapy
• 27% received massage or chiropractic services
• 34% attended church services
• 24% kept a personal diary

These research findings clearly demonstrate the wide variety of self-care activities employed by therapists to deal with the unique hazards of our profession.

Reflective questions:

• Do you feel that your self-care is effective for you?
• Have your practices of self-care changed over time? If so, how?

The Joys and Rewards of Practice

Having an effective, personalized self-care plan can help you stay present to the joys and rewards of practice. Skovholt (2001) describes some of the joys of practicing therapy, such as hitting a bulls-eye of success with a client. In their research, Radeke and Mahoney (2000) listed therapists’ endorsement of the following ways being a therapist has impacted their lives:

• 94% made me a better person
• 92% made me a wiser person
• 92% increased my self-awareness
• 90% appreciation for human relationships
• 89% accelerated psychological development
• 81% increased tolerance for ambiguity
• 75% increased capacity to enjoy life
• 74% felt like a form of spiritual service
• 61% resulted in changes in my value system

From these findings, it is clear that we benefit in many ways from the type of work that we do. According to Kramen-Kahn and Hansen (1998), some of the most frequently endorsed occupational rewards were:

• 93% promoting growth in a client
• 79% enjoyment of work
• 76% opportunity to continue to learn
• 73% challenging work
• 71% professional autonomy-independence
• 61% increased self-knowledge
• 56% variety in work and cases
• 56% personal growth
• 51% sense of emotional intimacy
• 39% being a role model and mentor

Staying connected to the rewards of practice, and to your higher purpose, is a wonderful vaccine for the hazards associated with being a psychotherapist. The quality of our life is deeply affected by the degree of purpose and engagement we feel at any given time. People who cope well with stress have a sense of meaning and purpose in their lives. There is value to periodically considering what we find significant.

The process of increasing our sense of meaning and purpose in life involves defining “success” and making very hard choices in light of very real limits of time and energy (Baker, 2003).

Reflective questions (Norcross & Guy, 2003):

• Can you identify and/or resonate with an abiding mission or sense of spirituality?
• Consider that good therapy does not provide meaning, but that a life of deep personal meaning creates effective therapy.
• Does your mission connect you to larger social or societal concerns? If so, how?

References

Alterman, S. R. (1998). Understanding clinician selfcare. Unpublished dissertation, The Chicago School of Professional Psychology.

Baker, E. K. (2003). Caring for Ourselves: A Therapist’s Guide to Personal and Professional Well-Being. Washington, DC: American Psychological Association Press.

Carroll, L., Gilroy, P. J., & Murra, J. (1999). The moral imperative: Self-care for women psychotherapists. Women and Therapy, 22, 133- 143.

Faunce, P. S. (1990). Self-care and wellness of feminist therapists. In H. Lerman & N. Porter (Eds.), Feminist Ethics in Psychotherapy (pp. 123-130). New York: Springer Publishing Company.

Kramen-Kahn, B. & Hansen, N. D. (1998). Rafting the rapids: Occupational hazards, rewards, and coping strategies of psychotherapists. Professional Psychology: Research and Practice, 29, 130-134.

Mahoney, M. J. (1997). Psychotherapists’ personal problems and self-care patterns. Professional Psychology: Research and Practice, 28, 14-16.

Margison, F. (1997). Stress and psychotherapy: An overview. In V. P. Varma (Ed.), Stress in Psychotherapists (pp. 210-234). London: Routledge.

Norcross, J. C. (2000). Psychotherapist self-care: Practitioner-tested, research-informed strategies. Professional Psychology: Research and Practice, 31, 710-713.

Norcross, J. C., & Guy, J. D. (2003). Leaving it at the office: Psychotherapist self-care. New York: Guilford Press.

Radeke, J. T., & Mahoney, M. J. (2000). Comparing the personal lives of psychotherapists and research psychologists. Professional Psychology: Research and Practice, 31, 82-84.

Sherman, M. D. (1996). Distress and professional impairment due to mental health problems among psychotherapists. Clinical Psychology Review, 16, 299-315.

Sherman, M. D., & Thelen, M. H. (1998). Distress and professional impairment among psychologists in clinical practice. Professional Psychology: Research and Practice, 29, 79-85.

Skovholt, T. M. (2001). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and professionals. Needham Heights, MA: Allyn & Bacon.

Walsh, S., Nichols, K., & Cormack, M. (1991). Selfcare and clinical psychologists: A threatening obligation? Clinical Psychology Forum, 37, 5-7.

Wood, B. J., Klein, S., Cross, H. J., Lammers, C. J., & Elliott, J. K. (1985). Impaired practitioners: Psychologists’ opinions about prevalence, and proposals for intervention. Professional Psychology: Research and Practice, 16, 843-850.

Eric S. Nicely, Psy.D., is a licensed psychologist in private practice in San Francisco. He is also an adjunct faculty member of Alliant International University. He is the facilitator for a Therapist Self-Care conference held two times each year in Tuscany (http://www.italyconferences.com).

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