Erica Wise, PhD, Matt Hersh, Clare Marks Gibson
In this article we will discuss ethics and self-care from the perspective of the three stages of professional development represented by the authors: an advanced graduate student intern (CMG), a recently licensed early career psychologist (MAH) and a later career psychologist (EHW). It is our hope that this article will raise awareness of the importance of self-care and positive ethics as well as the unique personal and professional stresses and ethical pitfalls that each developmental stage engenders for psychologists across the professional lifespan. Moreover, we aim to foster greater attention to effective self-care for psychologists as they transition from graduate school, internship and postdoctoral training into sustained (and sustainable) professional practice. In order to bring the issues to life, we will integrate developmental professional vignettes into our discussion.
It is useful to consider why we are embedding our discussion of self-care in an ethical context. Are these concepts well-suited to an integrated consideration? And--if so—how? The conceptual and intellectual response is that they are indeed related at both a surface and at a deeper and more nuanced level that we will explore in depth in the next section and through our analyses of self-care vignettes. Clinically, we know, for example, that the majority of psychotherapists admit to instances of working when too distressed to be effective and that nearly all of those surveyed acknowledge that doing so is unethical (Pope, Tabachnick, & Keith-Spiegel, 1987). Moreover, given that approximately half of psychotherapists have histories of various forms of abuse and family dysfunction (Racusin, Abramowitz, & Winter, 1981), it is imperative for helpers to help themselves too and to cultivate their own capacity for sustainable wellness as well as awareness of blind-spots. There is an additional rationale for promoting the integration of ethics and self-care in that recent survey research suggests that the inclusion of ethics content improves the appeal of continuing education workshops to participants. For example, in a survey of over 6,000 psychologists concerning their participation in continuing education, it was reported that ethics was the most frequently selected topic (Neimeyer, Taylor, & Wear, 2010). It is likely that this preference is influenced by regulatory mandates in that laws in 29 (57%) states specifically mandate continuing education in ethics for licensure renewal (Wise, 2010); however, there does seem to be a genuine interest in ethics education among psychologists, given that it is the most frequently selected focus of continuing education even in states that do not mandate its inclusion (Neimeyer et al., 2010). Our hope is that psychologists are attracted to ethics for aspirational and not solely for legally mandated or risk management reasons. Even though psychologists may “come” for the ethics, we are hopeful that they will “leave” with a renewed and enhanced commitment to ethical practice and self-care.
How might we best consider the integration of self-care and ethics at a conceptual level? Although self-care is not directly addressed in the APA Ethics Code (APA, 2002), competence is a cornerstone ethical obligation for psychologists. The last sentence of General Principle A: Beneficience and Nonmaleficence captures the interface between personal wellness and competence: “Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work” (APA, 2002, p. 1063). In the enforceable sections of the code, Section 2 contains the ethical standards that clearly relate to competence, and less directly to self-care and wellness. Section 2.01, Boundaries of Competence (a) states the basic expectation that “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (APA, 2002, p. 1063). Section 2.03, Maintaining Competence, reminds us that “Psychologists undertake ongoing efforts to develop and maintain their competence” (APA, 2002, p. 1064). While not explicitly stated in Standard 2.03, it is generally assumed that the term ongoing efforts refers to education and training rather than to self-care and wellness.
In contrast, Standard 2.06, Personal Problems and Conflicts, is clearly focused on the potential negative impact that personal problems may have on professional competence. It is interesting to note that the term conflicts appears only in the title rather than in the text; presumably the intent is to invoke the tension that occurs when there is a discrepancy (hence conflict) between our responsibilities and our abilities. In reviewing Standard 2.06 from the perspective of self-care and wellness, it becomes apparent that the enforceable sections of our ethics code are focused on protecting those with whom we work from our personal problems, rather than on the maintenance of wellness. We would suggest that psychologists expand the notion of ongoing efforts as stated above under Standard 2.03 to include a focus on personal wellness and self-care, even though this is not explicitly required by our code or by mandatory continuing education requirements as currently established by the Boards of Psychology that regulate practice (Wise & Gibson, in press). Standard 2.06 is excerpted below since is it central to the ethical focus of this article:
2.06 Personal Problems and Conflicts
(a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.
(b) 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, 2002, p. 1064).
Definitions and Concepts
There has been increasing awareness in our profession of the important role that self-care plays in the development and maintenance of competence. The stress-distress-impairment-improper behavior continuum proposed by the APA Board of Professional Affairs Advisory Committee on Colleague Assistance (ACCA, n.d.) provides a robust model for considering the impact of stress and coping in the lives of graduate students, interns, and practicing psychologists at various stages of professional development
Stress Distress Impairment Improper Behavior
In this model, stress is defined as our body’s reaction to demands that are placed on it that are generated from either internal (e.g., self-expectations) or external (e.g., work-related) sources, whereas distress is defined as the subjective state of reacting to either internal or external stress. As defined in this model, distress also may be caused by reactions to past events that are unresolved. Impairment refers to an objective change in the psychologist’s professional functioning that may result in ineffective services or cause harm to those with whom we work and improper behavior refers to professional behaviors that clearly cross ethical boundaries. Examples of impairment would include being late for appointments, the failure to return phone calls, or to complete reports in a timely manner; examples of improper behavior would include sexual or fiscal improprieties.
What do we mean by self-care?
Let’s shift our attention to a consideration of self-care, an increasingly emphasized area of professional development. While this topic has generally received less attention than stress, distress and impairment, the concepts are inevitably linked and intertwined. Self-care can be considered a multi-dimensional, multi-faceted process, one that, at its core, involves consciously giving care to one’s body, mind, and spirit (Orem, n.d.) to sustain healthy functioning and enhance well-being. Specific self-care content can be drawn from many sources including but not limited to spiritual and religious traditions, secular mindfulness-based approaches, therapeutic lifestyle changes (see Walsh, 2011), and the wealth of wisdom from our own profession. We focus on one particular approach promulgated by Norcross and Barnett (n.d.) that is flexible, principles-based, and quite comprehensive. In addition to providing an excellent model for incorporating self-care into our lives in a realistic and effective manner, it was explicitly developed to apply to our work as psychologists.
Norcross and Barnett recommend the flexible incorporation of 12 basic principles or strategies (as opposed to specific techniques) that are excerpted and adapted below with brief definitions; we refer the reader to the full article that was previously published in The Register Report and to the related book for a more in-depth discussion of strategies for psychologist self-care (Norcross & Guy, 2007). These 12 self-care principles are briefly summarized in the table below and will be referenced in the developmental stage discussions that follow.
Self-Care Principles Examples, strategies and applications
- Valuing the Person of the Psychotherapist Apply the skills that we use for clients to ourselves.
- Refocusing on the Rewards Remember to focus on the benefits and privileges of our work; practice gratitude.
- Recognizing the Hazards Acknowledge and accept the occupational challenges that are endemic to our field.
- Minding the Body Remember to practice the essentials of healthy living; sleep, eat and exercise well.
- Nurturing Relationships Cultivate support among colleagues, family members, friends and mentors. Ask the question, “Who has my back?”.
- Setting Boundaries Establish and maintain boundaries between yourself and others; between your personal life and your professional life.
- Restructuring Cognitions Notice perfectionistic and self-critical thoughts; manage them with compassion.
- Sustaining Healthy Escapes Seek restorative activities that keep you vital and engaged.
- Creating a Flourishing Environment Intentionally create a positive environment for yourself in terms of setting, colleagues and comfort.
- Undergoing Personal Therapy Engage in personal psychotherapy on a periodic basis as a form of positive self-development. Consider alternative approaches such as taking a yoga or meditation class.
- Cultivating Spirituality and Mission Connect to sources of meaning and values in your life.
- Fostering Creativity and Growth Diversify your professional activities; seek growth, development, change and renewal in your work.
What are the developmental factors that impact psychologists across the professional lifespan? Blustein (n.d.) suggests that normative developmental experiences (e.g., creating a stable partnership, giving birth to children, caring for aging parents) all impact the self and hence the professional functioning of psychologists. In addition, there is some intriguing data regarding disciplinary actions that may shed light on this question. In a review of national disciplinary data, Hall and Boucher (2003) determined that the average elapsed time between date of licensure and first disciplinary action was 20.8 years, that 94.5% of discipline occurs more than five years after licensure and that 70% of disciplinary actions occur between 11-35 years of practice. Why are we seeing more disciplinary problems later in the careers of psychologists? While we can’t provide a definite answer to this question, it is likely that as we move further from our foundational academic training we may experience a subtle deterioration in professional competence that is not adequately addressed by current mandatory continuing education standards. There may also be an insidious accrual of personal and family stressors that have the potential to undermine personal wellness and lead to increased risk of improper behavior. The findings described above underscore the importance of maintaining professional competence via the practice of personal self-care and engagement in activities that foster life-long learning.
Examples, strategies and applications
1. Valuing the Person of the Psychotherapist
Apply the skills that we use for clients for ourselves.
2. Refocusing on the Rewards
Remember to focus on the benefits and privileges of our work; practice gratitude.
3. Recognizing the Hazards
Acknowledge and accept the occupational challenges that are endemic to our field.
4. Minding the Body
Remember to practice the essentials of healthy living; sleep, eat and exercise well.
5. Nurturing Relationships
Cultivate support among colleagues, family members, friends, and mentors. Ask the question, "Who has my back?"
6. Setting Boundaries
Establish and maintain boundaries between yourself and others; between your personal life and your professional life.
7. Restructuring Cognitions
Notice perfectionistic and self-critical thoughts; manage them with compassion.
8. Sustaining Healthy Escapes
Seek restorative activities that keep you vital and engaged.
9. Creating a Flourishing Environment
Intentionally creat a positive environment for yourself in terms of setting, colleagues and comfort.
10. Undergoing Personal Therapy
Engage in personal psychotherapy on a periodic basis as a form of positive self-development. Consider alternative approaches such as taking a yoga or meditation class.
11. Cultivating Spirituality and Mission
Connect to sources of meaning and values in your life.
12. Fostering Creativity and Growth
Diversify your professional activities; seek growth, development, change and renewal in your work.
What are the specific developmental stressors that occur at developmental milestones for psychologists? We know little about stress and distress throughout the professional development of the psychologist and even less about the effective implementation of stage specific self-care strategies. What follows in each subsequent section is a discussion of common stressors, a developmentally-tailored vignette, and some initial suggestions for stage-specific coping strategies. These vignettes and subsequent analyses reflect both the universal principles (i.e., self-care principles that are applicable across the development of a psychologist) and stage-specific principles that are mostly unique to that particular period of development. We also want to highlight that each individual, depending on their particular strengths, vulnerabilities, and life values, will have certain principles that resonate with them. It is our hope that we can learn to identify, as early in our careers as possible, the universal principles that are most meaningful to us and begin to integrate them with stage-specific strategies throughout our professional development.
As you read each of the three vignettes below, we invite you to consider the following questions before reading our post-vignette analyses:
- Where is this graduate student or psychologist on the stress-distress continuum?
- What are the unique developmental stressors in this scenario?
- What are the applicable ethical considerations, both from aspirational and enforceable standards perspectives?
- What are some likely red flags, personal and professional, that would be important to attend to?
- Which self-care principles could be implemented for enhanced well-being and personal-professional life balance?
Graduate Student Therapists
Self-care is often overlooked or not explicitly discussed in graduate education. We are convinced that it is critical to learn sustainable self-care habits early in training and that it is the responsibility of both student and system to cultivate such a wellness-oriented perspective throughout training. Despite an assumption by educators and supervisors that they have provided sufficient instruction and structure to graduate students as they begin clinical work, this may not be the case. In fact, when training programs fail to attend to student self-care, the stress level of the students tends to increase (Dorff, 1998).
As students begin clinical work, there are unique stressors that more advanced and even early career psychologists may have long forgotten. There is both excitement and intimidation at the prospect of becoming a therapist. Novice psychotherapists are still learning to navigate the new role of clinician as they attempt to help those who are suffering. This new “crisis” of identity can also manifest in uncertainty about how they should refer to themselves and how to demarcate boundaries with clients (e.g., “How do I refer to myself with clients; what do I suggest that they call me?” “Can my clients call me on my cell phone?” “How do I allow for reduced fees or not charge for a missed session without devaluing myself and the profession?”). Despite the fact that programs typically have policies and procedures in place, they may not be clearly addressed or understood. The academic demands of graduate school compound the anxieties that accompany this identity shift. Graduate student therapists are involved in coursework, research, assistantship positions and a myriad of other responsibilities that can overwhelm a graduate student’s ability to use effective coping skills and pose challenges to wellness.
Additionally, as graduate student therapists progress through their training, another large source of stress related to training is the looming application and match process for the internship. Early in training, graduate students hear from their more advanced peers and faculty about the infamous match process and internship imbalance. It is important to keep in mind that students are participating in this process while actively treating clients. The internship application process in of itself can undoubtedly exacerbate stress as students think about leaving their geographic area, moving away from loved ones, and contemplate the prospect of not matching. Consequently, graduate student therapists can easily become overwhelmed with the addition of clinical duties and lack of guidance on how to manage stress and distress and how to promote well-being. A downward spiral can accelerate when high achieving graduate students become stressed that they are stressed!
Throughout the challenging process of clinically-focused education, there are also opportunities for graduate student therapists to start attending to self-awareness and noticing strengths and vulnerabilities. Throughout training, students are exposed to new therapeutic concepts and perspectives. Students learn techniques and approaches to use with their clients and may become aware that these can be applied to their own well-being. One technique in particular that has shown promise for use by trainees is mindfulness. Shapiro, Brown & Biegel (2007) found that a mindfulness-based stress reduction in trainees was related to increased positive affect and self-compassion. Meditation training in trainees has even been related to better outcomes in clients in one initial study (Grepmair et al., 2007). Mindfulness and meditation may be useful approaches to incorporate for all trainees as they promote self-awareness and compassion for themselves and others (see Christopher & Maris, 2010 for more about integrating mindfulness into training programs).
In considering the stress, wellness and functioning of graduate student therapists, it should be acknowledged that graduate training programs are potentially an important source of wellness and support. Graduate student therapists are under supervision and often have academic mentors and fellow graduate students with whom they can consult. Indeed, the quality of the relationship between student and academic advisor has been shown to be an important factor that is linked to stress in graduate student therapists (Cahir & Morris, 1991). Thus, we would strongly encourage students, supervisors, and training programs alike to increase their awareness of the triggers of stress and personal-student life imbalances and to emphasize prevention and early intervention. The implications for life-long ethical practice and the well-being of practitioners and clients are profound.
Graduate Student Therapist Vignette
You are a fourth year graduate student in clinical psychology program across the country from where you grew up. When you moved to attend graduate school, you left behind many family members, including your partner, and close friends. You have just started a new practicum at a community clinic for 15 hours a week. You are excited about the practicum particularly because the majority of the clients are from a diverse background, very different from your own. You would like to find time to read more about their cultures and look in the literature for treatment considerations within these cultures, but you just cannot find the time. You are working on your dissertation and have two manuscripts you are preparing to submit. You also are a teaching assistant for an introduction to psychology course and are taking a required biopsychology course. You have found it hard to keep up with your responsibilities. You have not been sleeping well since you are up late writing and responding to undergraduate’s emails from the psychology course. A few weeks into your current practicum, you have been late to two patient appointments, and not completed an assessment that is long overdue. A few of your clients do not appear to be making the progress you hoped for. You start to become discouraged and noticed yourself zoning out during sessions or thinking about your next obligation. In an attempt to help your clients, you tell one of your high-risk clients (a client who has a suicidal background) to call you anytime they are in distress. You provide them with a cell number, house phone and email address. You have recently not followed up on a client referral your supervisor assigned to you because you do not think you can take on another case. You tell your supervisor that the client’s contact information is out of date because you cannot bring yourself to admit you are overwhelmed. You are concerned that this would be interpreted as a sign of weakness and might even affect your evaluation; you are hoping this supervisor will write a strong letter of recommendation for internship. You start to think: “Did I choose the right profession? Is this what it is going to be like for the next thirty plus years? Can I really help these individuals? Can I help myself?”
Even if you are years removed from this stage of your training, you may still be able to recall and relate to the graduate student pressures that can disrupt clinical work. In this vignette, the student is certainly experiencing stress, distress and impairment (late for clients, late in getting a report done, not following up on a referral) and is at risk for improper and unethical behavior (poor boundaries, disrupted competence). In this stage of training, graduate student therapists are expected to broach such issues with their supervisors and we would encourage them to do so. However, graduate students may face internal and external barriers to raising these concerns in supervision. The issue of evaluation was also raised in this vignette. Evaluation is not intended to be a disempowering process but rather a constructive means of helping a trainee grow; however, this student is concerned about being viewed as incompetent or incapable. Many have not yet learned that self-care is a life-long process and very much a part of normative professional development. This student is not aware that the supervisor might very well be able to relate to these concerns and be supportive of self-care. The supervisor in this vignette might even serve as a model for effective self-care by sharing with the student a few selected examples of their own challenges and coping strategies. The graduate student in this vignette is undoubtedly struggling with personal stressors (e.g., concerns about effectiveness, lack of support) and academic hurdles (e.g., dissertation, coursework) that are impacting clinical care. The student may not be completely present in sessions, instead focusing on external demands and maybe even perceived inabilities. The student is also not able to find time to increase an understanding and knowledge of this new cultural group; a factor that might further compromise clinical learning and competence. These struggles with clinical care further contribute to this student’s sense of inadequacy. This then may result in less self compassion, increased negative emotions, and disengagement from both graduate and personal life. We can imagine that this student might begin to lose contact with friends and families. Some of the disconnection may be related to geography, but it could also be a result of not scheduling time to talk and more generally losing sight of personal values. In the avoidance of sharing with supervisors and in losing touch with friends and family, this student becomes even more vulnerable to the negative impact of stress and would clearly benefit from integrating self-care and achieving balance.
In turning to Norcross and Barnett’s (n.d.) self-care principles, a few may be particularly pertinent to the graduate student therapist in this vignette and likely many other trainees. Principle #1, Valuing the Person of the Psychotherapist, is considered a foundational strategy. A student’s vulnerabilities and strengths should be carefully assessed. Students will only be able to recognize where they are on the stress-distress continuum through self-awareness, and thus it is necessary to integrate this into one’s professional repertoire early in training. This self-awareness could be expanded through a strengths-based approach to evaluation. That is, an evaluation process that highlights the abilities and skills that a student brings to their clinical work. Similarly, mindfulness-based approaches as mentioned earlier could be another avenue to fostering self-awareness. In principle #4, Minding the Body, the trainee may take measures to help incorporate an adequate sleep schedule. This may mean making some adjustments to their day, but it would help increase wellness and resiliency. Nurturing Relationships (principle #5) would address the lack of social supports. This student would benefit from increasing a social network to connect with and seek support from. This student could seek support from a clinical supervisor or mentor. As mentioned, these relationships are critical to a trainee’s wellness in graduate school. Student therapists have access to supervisors to discuss such matters as countertransference and personal concerns as they relate to clinical care. When in the early stages of clinical training, as students are struggling with their identity, they may be embarrassed or reluctant to raise such concerns or questions as Bruch (1974) has noted in her writing for therapists in training. Thus, a supportive supervisory relationship can facilitate trust and openness and provide a safe space for the student to start identifying his or her strengths and vulnerabilities. A graduate student process or support group is another excellent venue for discussion of self-care and can simultaneously build a support system. Being mindful not to take on extra obligations, this student could consider finding one social activity to help build a social network outside of school. In attending to the potential boundary implications, principle #6, Setting Boundaries, can be useful. Through supervision, this student could recognize the blurring of boundaries and might additionally benefit from the realization that actively deciding not to take on another client is actually practicing good self-care and not a sign of weakness. The impact that personal life and academics have on well-being and clinical care would underscore the need to set boundaries. Lastly, students may start to wonder if they have chosen the right career. In Cultivating Spirit and Mission (principle #11), students could reconnect with what initially brought them to graduate school for psychology and what excites them about the profession. Remembering one’s professional mission and working towards those values can help promote wellbeing and personal strength in psychology trainees.
Early Career Psychologists (ECPs)
At every stage of professional development practicing psychologists contend with universal stresses and ethical dilemmas – givens for being both human and a therapist. When we look at the unique developmental aspects of ECPs, however, we find particularly interesting opportunities for exploring the intersection between therapist self-care and ethical practice. Developmentally, ECPs are betwixt and between. Unlike graduate students, interns, or even some postdoctoral fellows, ECPs are no longer under the direct care and (licensed) supervision of mentors, of those from whom they have directly learned and with whom they have grown both personally and professionally. Compared to mid and later career psychologists in practice, ECPs, simply by virtue of less experience in the practice (and often personal) world, have more uncharted territory to discover and through which to navigate. Both the veneer and enticement of independence as a newly-born professional - especially after securing the privileged role of licensed clinician after such a long and arduous training period - can sometimes be quite frightening and discombobulating, as Green and Hawley (2009) compassionately suggest. In short, ECPs can be considered to be in a constant state of becoming (despite feeling like finally just being), which calls for an ECP-tailored form of self-care and professional-personal life balance.
Today’s ECPs find themselves in somewhat of a different position than those in previous generations. The vast majority of ECP’s are women (74%), and are, on average, 39 years of age. Over one-third of practicing PhD’s, for example, enter the workforce with over $50,000 in debt (Michalski, 2009). These facts have sobering implications for both professional and personal identity development as well as for sustainable personal self-care and work-personal life balance. Lack of financial solvency may drive many ECPs to take on two or three jobs at once (e.g., day-time group clinical practice, evening private practice, and nightly teaching) to make ends meet and to pay down debt (e.g., Green & Hawley, 2009). This may be particularly salient and challenging when the ECP (who is very likely to be a woman) has a family to raise and support.
If ECPs have delayed starting a family until some semblance of financial stability, it is precisely at the time they are building their own identities (and practices) as independently licensed therapists that they also are taking on the new role of parent. The challenge of simultaneously growing a practice and a family cannot be overstated. Attending to self-care may then seem like the lowest priority for the ECP who feels that family, financial stability, reputation, credentials, and further education are demands that cannot be ignored. What follows in the sections below is a call for a compassionate awareness of just some of the challenges with which the ECP contends. We hope that this writing will be considered a gentle push for reflection rather than prescription. As Jung (1955) noted, “The shoe that fits one person pinches another; there is no recipe for living that suits all cases” (p. 69).
One essential and perhaps foundational ingredient in the endeavoring of ECP self-care is mindful awareness - at once a precise, gentle, and big-picture awareness of all that the ECP is currently experiencing and perhaps trying hard to grasp or avoid. This kind of self-reflection may be a necessary cornerstone for integrating personal and professional self-care into the ECP’s life, in accordance with the ECP’s own values. Following from this, we suggest the real-world practice of the “mindful check-in,” which is an ongoing self-compassionate assessment of the quality of ECPs’ presence of mind within or surrounding any given activity or aspiration. Is the ECP’s state of awareness distracted by plans and ambitions for all that he or she could be doing that the here-and-now (both personally and professionally) begins to suffer? Is there a dwelling in the feeling of “what should have been” at the cost of being in the present with what is, no matter how unpleasant the present may be? How can the ECP endeavor to balance two vital efforts: one focused on planfulness and future-oriented thinking in the service of building one’s practice and therapist identity, and the other centered around staying grounded in the present moment(s) in the service of more calm and authentic connection with clients, colleagues, and loved ones and gratitude for what the ECP already has managed to accomplish?
Early Career Vignette:
You were licensed last year and just landed your first post-licensure job in
a combined child and adult group practice of mostly psychiatrists and one
senior psychologist who is to retire in the next few months. You are very excited to finally be in a group psychiatric practice after being at a hospital postdoctoral fellowship in which there were only technicians, nurses, and one other much older, highly pessimistic psychologist. The recently hired administrative assistant, who appears very supportive, friendly, and psychologically-minded, fortunately facilitates all of the billing and scheduling concerns. Nearly one-third of your gross revenue contributes to the maintenance of the group practice, and you discover several months into your job that the psychiatrists take home more of their earned revenue than you do. Although several of the psychiatrists are nice and experienced enough, you haven’t found anyone there who would seem to be a supportive mentor educated in the specific practice and ongoing training as a clinical psychologist. Because you are fully licensed now, you are asked by the practice director to take on many of the higher-risk suicidal and emotionally unstable patients. The psychiatrists need more medication-only appointment slots available, and they cannot take on any more of these higher-risk cases for psychotherapy. Although you have not been trained extensively in therapy for such high-risk groups, you feel compelled but also excited to see these patients. You decide that taking on this new high-risk caseload is tempered by the fact that you also have the opportunity to work with the exact patient population with whom you were trained for therapy: youth with Autism spectrum disorders. Although you had initially negotiated a 30 hour/week schedule (due to child care for your baby and a desire to diversify your professional life into other meaningful areas), the high-risk patients with whom you are now working necessarily demand significantly more time from your schedule than was previously desired or anticipated. In fact, several patients have called you in crisis after hours. Tonight is the sixth night in the last two months that you have arrived home late to relieve your partner for child-care responsibilities.
This hypothetical scenario may not be far from some ECPs’ experiences, with some exceptions of course. Let’s first consider this ECP’s physical/mental status and placement on the stress-distress continuum. This ECP is likely experiencing several overt (e.g., sheer volume of higher-risk caseload) and some more insidious stressors (e.g., spillover of professional responsibilities into home life; seeing high-risk patients with less experience than desired; less supportive atmosphere than hoped for). We are not made aware of the subjective emotional/physical state of the ECP, but we might conjecture that there may be several manifestations of distress, experienced both during the work day and when at home in the evening and in the morning before leaving for work. Although there are no obvious signs of impairment or improper behavior, we might pause here for both an aspirational as well as standards-based ethical examination. Principle A essentially has us aspire to do no harm and to benefit the client as much as we can. Might this ECP be at risk for doing harm and not benefitting his/her higher-risk patients for whom he has not received adequate prior training? This concern becomes particularly salient as we consider that this ECP does not have an immediate in-house network of psychologists with whom to consult, although the ECP may need to move past the desire to be mentored by another psychologist at this time and at least discuss some cases with a psychiatrist willing to donate a few minutes each week. We also might safely assume that the ECP’s personal and family time is being compromised not only by after-hours clinical calls but also by virtue of the time and energy it often takes, particularly for less trained and experienced therapists, to formulate, treatment plan, and provide crisis management for such high-risk cases. Furthermore, if we take a leap forward for a moment, we might also hypothesize that because the administrative assistant is especially supportive, friendly, and psychologically-minded, the ECP might experience an inevitable pull and gravitate towards periodic conversation, informal consultation, and perhaps more boundary-diffuse interactions over more personal as well as more professional issues.
That this ECP is a new parent may bring additional challenges regarding a range of stress spillovers from home to work (e.g., exhaustion and quality of partner relationship) and from work to home (e.g., compassion fatigue allowing for less compassion and patience for partner and child). As described earlier in this article, Standard 2.06 states that psychologists refrain from professional activities when they are aware that their personal problems may diminish their capacity to competently perform work-related services. Certainly, extreme and chronic exhaustion can be as toxic as some illicit substances vis-à-vis attentional deployment and mood reactivity. And a vicious cycle may ensue in which compassion fatigue at work may compromise interpersonal relations at home, subsequently leading to less patience when with high-needs patients. These are but some of the issues of which this ECP likely needs to be mindfully and compassionately aware.
From the issues provoked by this vignette, we first can turn to the practice of the mindful check-in to consider how this ECP may reflect, with a self-compassionate stance, on his/her over-striving (and/or feeling compelled) to take on more than is humanly possible at this time. While it is the norm for hard-working psychotherapists to work hard, over-working and working outside the scope of one’s professional training should not be condoned, not matter how alluring. It is this particular way of working that is precisely what can impede an integration of consistent self-care and potentially lead to professional burnout and personal disillusionment. In balancing the two vital efforts of forward thinking with present-moment connection, this ECP may benefit from a self-reflective pause to consider which life values, personally and professionally, are most meaningful and most in need of gentle examination. It is from this reflection on what is truly most meaningful in the ECP’s life at this time that we can then entertain developmentally significant principles for sustainable self-care.
We turn to Norcross and Barnett’s (n.d.) 12 principles for effective self-care, four of which may be particularly salient to ECPs’ management of identity development, work style, and personal well-being. Principle #3, Recognizing the Hazards, could not be a more appropriate form of personal and professional preventive self-care. Many ECPs find themselves “in over their heads” by virtue of all of the developmental identity issues we have described above. To be self-compassionately aware of the universality of such a situation is a wise foundation from which to begin. Practicing acceptance of this notion while also taking concrete steps to mitigate excessive fatigue and distress, for example, are additional layers of self-care that may come next. Concrete steps may include, but are certainly not limited to, Minding the Body (principle #4), Nurturing Relationships (principle #5), and Setting Boundaries (principle #6).
At the often stressful junctures many ECPs find themselves are also wonderful opportunities to pause and examine how we are taking care of our physical selves – from the art of refreshing our minds and bodies (through 10 simple deep breaths) in between highly emotional and challenging client sessions to valuing the sleep we get each night in order to pay “complete” attention to our clients the next day. Nurturing existing relationships while fostering new and supportive ones can be considered one of the best forms of stress management and positive self-care, particularly when it is so appealing for the ECP to get involved full force in a range of commitments in order to build reputation and credentials. Mindfully connecting with our loved ones outside of work and seeking out meaningful peer and mentor-based supervision for work has the potential to mean the difference between stress that feels manageable and stress that can lead to distress, impairment, and improper behavior. Finally, for the ECP who is likely to take on more than is humanly possible (which is quite the universal tendency), we must maintain boundaries within work and between work and personal life that preserve our dignity, our sense of wholeness, and our time and energy. When saying “yes” to any given task typically would not be questioned, we may engage in a mindful check-in and reflect on how our boundaries might be impacted, regardless of the appeal or the demanding nature of the task. And when we are home with our friends, partner, or family, let us simply be home. Let us commit to leaving work where it was, even for a few moments while we eat a good meal or feel a sense of connection with loved ones. We can let such self-compassionate pauses be our signposts for how we would like to conduct our professional and personal lives in the service of both optimal and humane living.
Mid to Late Career Psychologist
As discussed earlier, stressors tend to accrue as psychologists age. More seasoned psychologists in practice are further from their foundational training and are likely to experience other stressors and loss as a result of normative development. Those at the mid-career point may have families with older children, adolescents, and even young adults whose own stressors and challenges (and financial concerns) can certainly impact the psychologist’s daily state of mind, sense of financial stability, and ability to function optimally. As Blustein (n.d.) suggests, these psychologists, as well as those in their late career, may also be contending with the challenges of being in the “sandwich generation,” simultaneously taking care of and supporting their own children while caring for aging or ill parents. This middle-aged crunch calls for highly self-compassionate action and a set of realistic expectations about what is possible to achieve at any given time. Similar to both graduate student therapists and ECPs, self-care for mid to late career psychologists in practice may also present as a lower priority than it should. What follows is a vignette that is intended to capture some of the stressors associated with a mature, developed practice.
You didn’t sleep well the night before and you are starting the day exhausted. Your 1st client tells you that she needs you to complete an extensive outpatient treatment report by the next day so that she can have additional sessions approved. Your 2nd client reveals that he slapped his 12 year old son in the face for “talking back” (you make a note to consult a colleague when you have the time to determine if this might trigger a mandated report to DSS). When you check your mail between your 2nd and 3rd clients, you find a formal-looking envelope that contains a subpoena for “all clinical records” for a client whom you are treating for mild residual PTSD symptoms following a motor vehicle accident; she is now involved in civil litigation and her attorney wants to review your records. You had hoped to work over lunch on an overdue child custody report, but are too distracted to do so. Instead, you work on the 1st client’s outpatient treatment report and leave yourself a few minutes to check your voicemails. There are several: the first is from a young adult client telling you that she is in crisis and having thoughts of self harm, but needs to cancel her appointment for the next morning; the other is from your next client who is stuck in traffic—he hopes that you will give him extra time if he is late. There is also a message from your elderly mother telling you that she may need a ride to an important medical appointment the next day and you realize that you may need to reschedule a few clients if you can’t make other arrangements for her. By mid-afternoon, you realize that you will likely need to skip your after-work exercise class at the “Y” and your monthly book club gathering that evening (and you have actually read the book!) because you are just too exhausted. When you are finally on your way home after seeing 5 more clients, you decide that all you really want to do is watch TV and drink several beers when you get home and just “chill out” for the rest of the evening. You are aware that your book club friends will be disappointed. In addition, your partner and teenage children become frustrated when you don’t interact and “disappear” into the TV. You also recall that you had tentatively promised that you would help your 15 year with a science report that is due the next day. You generally enjoy being involved in school projects, but realize that you simply don’t have any more to give.
There are a number of issues embedded in this vignette and hopefully this is a more stressful day than most of us typically experience! As discussed earlier, there are now reasonably well understood occupational hazards associated with our work as psychologists (ACCA, n.d.; Norcross & Guy, 2007). Our work is inherently challenging at many levels, not least of which includes ethical and legal complexities (the potential mandated report for child abuse; the unexpected subpoena), and increasingly involves complex administrative and documentation components (the outpatient treatment and custody reports) and unpredictable client needs and schedules. In this vignette there is a mix of stress from a variety of sources, distress, impaired and possibly improper behavior. From many years in working with ethics committees and the North Carolina Psychology Board, the first author would have particular concern about the failure to rapidly address the potential child abuse issue, the client with thoughts of self-harm and the overdue custody report. A downward spiral of self-neglect (skipping exercise and opportunities for positive social engagement) and the resultant seeking of less adaptive coping behaviors may be an additional red flag. In reality, it may be challenging to effectively apply Standard 2.06. In fact, when we are emotionally exhausted, we may not easily, for example, identify the need to set boundaries with others or to establish effective priorities in our various tasks or otherwise follow the mandates of our ethics code. We also may experience the expectations of elderly parents, partners and children as intrusive, rather than positive when we become overwhelmed.
In considering the 12 self-care strategies Principle #1, Valuing the Person of the Psychotherapist is as critical a foundational strategy for the mid to later career psychologist as it is for the graduate student or ECP and would serve to draw attention to the need to take a step back and re-evaluate current stress levels and coping. Principle #2, Refocusing on the Rewards and Principle #3, Recognizing the Hazards, can serve to draw our attention to the opportunities for gratitude for the richness of our work and to remind us to stop and appreciate the benefits even on a busy or stressful day. Consideration of Principle #5, Nurturing Relationships, can serve as a reminder to connect with friends, family and colleagues even when we are feeling pressed and overwhelmed; maybe especially at those times. A commitment to implementing principle #6, Setting Boundaries, can assist us in establishing effective limits so that we preserve time and energy to deal effectively with our professional commitments and to engage with the people and activities we value in our personal lives.
In writing this article, the authors have noted that we have had to actively and consciously strive to maintain a positive emphasis on self-care. We have wondered if this tendency to be drawn to an examination of our short-comings may lead us to neglect to value the person of the psychotherapist (ourselves) to borrow the terminology of Norcross and Barnett. We have also wondered if this tendency may reflect a broader propensity in professional psychology to focus on pathology rather than wellness. Just as our field has been influenced in a beneficial manner by the growth of positive psychology, we hope that this article will inspire psychologists at differing levels of professional development to consider seriously their own strengths, health and wellness, in addition to their stressors and vulnerabilities. And, for those of us who are educators, trainers and supervisors, this article will hopefully serve as a call to address self-care and wellness in our academic programs, internships and professional communities. Professional psychology is a tremendously varied and rewarding field. Developing positive and sustainable patterns of self-care and competent practice are skills that we need to incorporate early in our training and endeavor to practice throughout our careers.
Dr. Wise is Clinical Professor and Director of the Psychology Training Clinic for the Department of Psychology at UNC-Chapel Hill. She teaches doctoral level courses that focus on clinical theory and practice, ethics and diversity. She is a former chair of the American Psychology Association's Ethics Committee and the North Carolina Psychology Board. Dr. Wise was recently elected to serve her second term on the National Register Board of Directors.
Dr. Hersh is in private practice in Cambridge, MA conducting psychotherapy for anxiety and mood difficulties for youth and adults. He also offers consultative workshops to organizations to help improve self-care skills, with a particular interest in helping psychotherapists integrate self-care into professional practice and personal life. Dr. Hersh's research interests include mindfulness therapies for youth, contemporary psychotherapy issues, and wellness. His personal meditation practice helps to inform both clinical and research endeavors. He received his PhD from UNC-Chapel Hill, with further training at Children's Hospital Boston/Harvard Medical School and BU's Center for Anxiety and Related Disorders.
Clare Marks Gibson, MA is an advanced clinical psychology doctoral student at UNC-Chapel Hill and is currently completing her internship with the Veterans Affairs Maryland Health Care System/University of Maryland-Baltimore Consortium. Clare's clinical and research interests are in psychotherapy for severe mental illness. Her professional interest is in the area of self-care for graduate students and interns. She has served as a graduate students member of the NCPA's Colleague Assistance Committee (CAC) and has written on the topic of self-care in clinical psychology graduate students.
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