John C. Norcross, PhD. and Jefferey E. Barnett, PsyD
*Adapted from Leaving It at the Office: A Guide to Psychotherapist Self-Care. (C) 2007 by John C. Norcross and James D. Guy. Adapted with Permission of The Guilford Press.
Positive ethics focuses the psychologist on constantly striving to achieve the highest ethical standards of our profession (Barnett, 2007). It eschews efforts to do the minimum, to get by, to avoid negative outcomes. It is guided by a series of aspirational virtues that we strive to achieve throughout our careers (Knapp & VandeCreek, 2006). These virtues include:
Beneficence: doing good and providing maximum benefit to those psychologists serve
Nonmaleficence: avoiding exploitation and harm of patients and those associated with them
Fidelity: being faithful to the explicit and implicit obligations psychologists have to their clients
Autonomy: promoting each client’s independence of us over time and not creating increased dependence on us through our actions
Justice: providing fair and equal treatment, and access to treatment, to all individuals
Self-care: providing adequate attention to our own physical and psychological wellness so that we are effectively able to implement the preceding virtues (Beauchamp & Childress, 2001).
In this article, we address the latter ethical imperative: self-care. Our principal aims are first, to remind busy psychologists of the personal and professional need to tend to their own psychological health, second, to review the ethical principles and standards associated with self-care, and third, to outline 12 evidence-based methods to do just that.
The Paradox and the Irony of Self-Care
Suppose you came upon a man in the woods working feverishly to saw down a tree. “What are you doing?” you ask. “Can’t you see?” comes the impatient reply. “I’m sawing down this tree.” You exclaim: “You look exhausted!” “How long have you been at it?” The man replies: “Over five hours, and I’m beat! This is hard work.” You inquire: “Well, why don’t you take a break for a few minutes and sharpen that saw? I’m sure it would go a lot better.” The man replies emphatically: “I don’t have time to sharpen the saw. I’m too busy sawing!”
Now impose that identical encounter onto a typical practicing psychologist. You see the psychologist working feverishly evaluating, treating, and assisting patient after patient. “What are you doing?” you ask. “Can’t you see?” comes the impatient reply. “I’m helping distressed patients.” You exclaim: “You look exhausted! How long have you been at it?” The psychologist replies: “Over five hours, and I’m beat! This is hard work.” You inquire: “Well, why don’t you take a break for a few minutes and replenish yourself? I’m sure it would go a lot better.” The psychologist replies emphatically: “I don’t have time to replenish myself. I’m too busy!”
That is the paradox of self-care: no time to sharpen the saw! The tale, incidentally, comes from Stephen Covey’s (1989, p. 287) The 7 Habits of Highly Effective People. It is so easy to see and diagnose it in other people; it is so hard to get off the treadmill ourselves.
Existential-humanistic psychotherapists Sapienza and Bugental (2000, p. 459) put the self-care paradox bluntly: “Many of us have never really learned how to take the time to care and to nourish ourselves, having been trained to believe that this would be selfish…. Nor have most psychologists taken the time to develop compassion for themselves, and compassion for their wounds.”
Not that psychologists oppose selfcare; far from it. Instead, we are busy, multitasking professionals dedicated to helping others but who frequently cannot locate the time to help ourselves. Clients, families, paperwork, colleagues, students, and friends frequently assume priority. The ideal balance of caring for others and for ourselves tends to favor the former.
The point segues into the irony of psychotherapist self-care: Not availing ourselves of what we provide or recommend to clients. We oftentimes feel hypocritical or duplicitous - suggesting to others that they work less, exercise more, renew themselves, and so forth – while we do not take our own advice. How often do we sit with patients encouraging them to “relax and take a vacation,” while calculating our lost therapy revenue and airfare and concluding we can’t afford to take the time away from the office right now (Penzer, 1984)?
A representative example from one of our workshop participants: “I had the ergonomic person here yesterday for an analysis in my office thanks to back pain that signals something negative to me. When I had to answer her questions about my amount of work, vacation, etc., it was embarrassing! How could I possibly with a good conscience give a talk on stress management when I behave as I do?” (On a positive note, the person optimistically concluded that “I’m assuming the universe is sending me needed messages and that your reminder e-mail about self-care is yet another.”)
It is easier to be wise and mature for others than for ourselves. If you are still feeling a little hypocritical, sheepish, or guilty about not practicing what you preach, then join us and the crowd. We are far more adept at recommending self-care to others than practicing it ourselves, as our families and friends will readily attest. We are in no position to moralize.
Mental health professionals frequently enter the profession out of a great desire to help others in a meaningful way. Most clinicians acknowledge the gratification they experience in assisting others to overcome challenges in their lives. Yet, this focus on the needs of others complicates our balancing act: effectively caring for ourselves while caring for others. Without our own ongoing self-care, we become increasingly more limited in our ability to effectively assist others. It is vital to strike a balance between ongoing self-care and our caring for others.
Psychotherapists frequently comment on the cruel irony of giving to clients what they deprive their families. One psychotherapist (Penzer, 1984, p. 54) notes the dissonance of “spending several hours a day playing Uno, Checkers, and War in the name of play therapy and coming home in the evening and casting my children’s requests aside in the name of fatigue.” Another colleague was conducting psychotherapy with a harried middle-aged father one evening and focusing on the father’s need to spend more time with his son and daughter. Alas, the therapist was seeing patients four evenings a week and ignoring his own young children! Many psychotherapists will candidly admit to giving more time, energy, and devotion to their practices than to their spouses, children, or themselves (Penzer, 1984). Take thine own medicine.
Just as being a lawyer does not necessarily make one more honest and being a physician does not necessarily make one healthier (Goldberg, 1992), so too does being a psychotherapist not make one automatically more proficient at self-care. In fact, ‘tis frequently the converse in a profession in which people enter “to help others.”
The Ethics of Self-Care
Almost every ethics code of mental health professionals includes provisions about the need for self-care. (Not the ethics code of psychiatry, by the way.) The 2002 version of the APA ethics code, for example, instructs psychologists to maintain an awareness “of the possible effect of their own physical and mental health on their ability to help those with whom they work” (p. 1062). Awareness is a critical first step, but much more is needed. Awareness alone, to paraphrase Freud, is like providing a starving person with only a dinner menu.
Standard 2.06 (Personal Problems and Conflicts) goes on to state (p. 1063):
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.
The American Counseling Association’s (2005) Code of Ethics, for another example, enjoins counselors to “engage in self-care activities to maintain and promote their emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities” (p. 9). Further, the Code states “Counselors are alert to the signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They seek assistance for problems that reach the level of professional impairment….” (p. 9).
Such ethics standards focus on existing problems and conflicts, which certainly represents sage advice. But a broader interpretation would be to prevent such circumstances from even occurring (Barnett, 2007). Self-care is not restricted to intervention after professional competence has been compromised; it is a continuous, proactive process throughout our careers.
Without attending to our own care, we will not be adequately able to help others and prevent harm to them. Psychotherapist self-care is a critical prerequisite for competent patient care. In other words, self-care is not simply a personal matter but also an ethical necessity, a moral imperative (Carroll, Gilroy, & Mura, 1999). We gently urge you to challenge the morality of self-sacrifice at all costs and to consider the indispensability of self-care.
Convergence of Science and Practice
The person of the psychotherapist is inextricably intertwined with treatment success. We know, scientifically and clinically, that the individual practitioner and the therapeutic relationship contribute to outcome at least as much as the particular treatment method. When not confounded with treatment, so-called therapist effects are large and frequently exceed treatment effects (Wampold, 2001, p. 200). Meta-analyses of therapist effects in psychotherapy outcome average 5% to 9% (Crits-Christoph et al., 1991; Wampold, 2001). A study estimated the variability of outcomes attributable to psychotherapists in a managed care setting involving 6,146 patients and 581 therapists. About 5% of outcome was due to therapist effects; 0% was due to specific treatment (Wampold & Brown, 2005). Despite impressive attempts to experimentally render individual practitioners as controlled variables, it is simply not possible to mask the person and the contribution of the therapist.
That contribution of the individual therapist also entails the creation of a facilitative relationship with a patient. The therapeutic relationship, as every half-conscious practitioner knows in her bones, is the indispensable soil of the treatment enterprise. Best statistical estimates are that the therapeutic relationship, including empathy, collaboration, the alliance, and so on, accounts for approximately 10% of psychotherapy outcome (Norcross, 2002). That rivals or exceeds the proportion of outcome attributable to the particular treatment method.
Suppose we asked a neutral scientific panel from outside the field to review the corpus of psychotherapy research to determine what is the most powerful phenomenon we should be studying, practicing, and teaching. That panel (Henry, 1998, p. 128): would find the answer obvious, and empirically validated. As a general trend across studies, the largest chunk of outcome variance not attributable to preexisting patient characteristics involves individual therapist differences and the emergent therapeutic relationship between patient and therapist, regardless of technique or school of therapy. This is the main thrust of three decades of empirical research.
Here is a quick clinical exemplar to drive the point home. It derives from a thought experiment (gedankenexperiment) we use in our clinical workshops. We ask participants, “What accounts for the success of psychotherapy?” And then we ask “What accounts for the success of your personal therapy?” The prototypical answer is “Many things account for success, including the patient, the therapist, their relationship, the treatment method, and the context.” But when pressed, approximately 90% will answer “the relationship.”
As a final illustration, we would point to studies on the most informed consumers of psychotherapy – psychotherapists themselves. In two of our studies in the United States and Great Britain, hundreds of psychotherapists reflected on their own psychotherapy experiences and to nominate any lasting lessons they acquired concerning the practice of psychotherapy (Norcross et al., 1988, 1992). The most frequent responses all concerned the interpersonal relationships and dynamics of psychotherapy: the centrality of warmth, empathy, and the personal relationship; the importance of transference and counter transference; the inevitable humanness of the therapist; and the need for more patience in psychotherapy. Conversely, a review of published studies that identified covariates of harmful therapies received by mental health professionals concluded that the harm was typically attributed to distant and rigid therapists, emotionally seductive therapists, and poor patient-therapist matches (Orlinsky, Norcross, Ronnestad, & Wiseman, 2005).
All of this is to say that science and practice impressively converge on the conclusion that the person of the clinician is the locus of successful psychotherapy. It is neither grandiosity nor self-preoccupation that leads us to psychotherapist self-care; it is the incontrovertible science and practice that demands we pursue self-care.
5 Fundamental Lessons
Our decades of researching, writing, teaching, and practicing psychologist self-care have taught us five fundamental lessons. When we ignore these lessons, our colleagues, students, and workshop participants fail to eagerly embrace a sustainable plan of self-care.
First, offer self-care principles or strategies, as opposed to specific techniques. Effective psychotherapist self-care is characterized by a complex, differential pattern of strategies. These strategies or principles represent an intermediate level of abstraction between concrete techniques and global theory. There are literally thousands of self-care techniques (e.g., meditation, assertion, dream analysis, vacations), and we cannot agree on a single theory (e.g., psychoanalysis, cognitive, systemic, narrative); however, research increasingly reveals that we can agree on broad principles. Given the diversity of individual preferences and available resources, we recommend broad strategies as opposed to specific techniques. If a colleague is plagued by occupational anxieties, the research suggests that the strategies of healthy escapes (reciprocal inhibition) and helping relationships may well prove effective. Once the strategies are identified, then the individual practitioner can discover for herself the available and preferred techniques for implementing these strategies; for instance, massage, exercise, and meditation for healthy escapes and peer support groups, clinical supervision, and more frequent contact with friends for helping relationships. The focus should be squarely placed on broad strategies, which you then adapt to your own situation and preferences (Norcross, 2000).
Research on self-care and coping has directed us to a second lesson: go broad instead of deep. There are appreciable outcome differences between various psychotherapist self-care strategies, but the effect of any single strategy is rather modest. The 12 self-care strategies recommended in a following section, for example, are demonstrably more effective than the passive strategies of, say, wishful thinking, self-blame, and substance abuse (Norcross & Aboyoun, 1994). At the same time, there is no single self-care strategy so outstandingly effective that its practice alone would ensure an ability to conquer distress. These findings suggest to us, as they have to others, that possessing a particular skill in one’s arsenal is less important than having a variety of self-care strategies. Seasoned practitioners have extended valuable lessons from their clinical work to their personal lives: avoid concentration on a single theory and promote cognitive and experiential growth on a broad front.
The third lesson we have learned over the years is to emphasize the interdependence of the person and the environment in determining effective self-care. The self-care and burnout fields have been polarized into rival camps. One camp focuses on the individual’s deficits – the “fault, dear Brutus, is in ourselves” advocates – and correspondingly recommends individualistic solutions to self-care. A second camp focuses on the systemic and organizational pressures - the “impossible profession with inhumane demands” advocates - and naturally recommends environmental and social solutions. We have learned to value both camps and adopt an interactional perspective that recognizes the reciprocal confluence of person-in-the-environment. The self is always in a system.
When conceptualizing the self-in-a-system, we repeatedly point to the unique motives, family of origins, and underlying psychodynamics of mental health professionals. What drives a person to concern himself with the dark side of the human psyche? What is it that compels certain people to elect to help those who are suffering, wounded, or dysfunctional? Assuredly they are a “special sort” since the average person prefers to downplay the psychic sufferings of fellow humans and avoid extensive contact with troubled individuals.
The question of motivation - Why did I (really) become a psychotherapist? - is obviously not a simple or entirely conscious one. To be sure, the altruistic motive “to help people” is one cornerstone of the vocational choice, but it is incomplete. It begs the deeper questions. Why is “helping people” of utmost concern for you? What makes it a deeply satisfying experience? Of all the helping careers - assisting the homeless, saving the environment, rendering public service, teaching the uneducated, tending to physical ills – why this career as a psychotherapist? Even the most saintly among us is moved by a complex stew of motives, some admirable and some less so, some conscious and some less so. Psychotherapists frequently report that they only come to realize the reasons they chose their discipline well into their careers or during the course of intensive personal psychotherapy (Holt & Luborsky, 1958).
The failure to consider the individual motives, needs, and vulnerabilities of the particular psychologist brings us to the fourth lesson: tailor self-care to the individual practitioner. Much of the well-intended practical advice on self-care bandied about feels hollow and general. One-size-fit-all treatments never accommodate many people, be it our clients or ourselves. We have learned – and repeatedly relearned – that sustainable self-care must occur in the context of, and be responsive to, the emotional vulnerabilities and resources of the individual clinician.
One size definitely does not fit all of us. A complex matrix of interacting variables - family background, training experiences, characterological vulnerabilities, socio-demographic diversity, professional discipline, personal values, practice setting, theoretical orientation, ad infinitum - reciprocally determine the eventual “distress” of the clinician. Similarly, what works for one of us in self-care - more contact with professional colleagues or more vacations - may well backfire for another of us. Finally, what works well at one point in one’s career may not be as effective at another. Changing circumstances, needs, and preferences must be considered.
A fifth and final lesson: embrace self-care both at the office and away from the office. One way to leave distress at the office is to enhance functioning at that same office. Not to frantically squeeze 10 hours of work into 8 hours and then expect to retreat peacefully to a safe haven elsewhere, for instance. Another way to leave distress at the office is to enhance one’s life outside the office: Enjoying your relationships, participating in healthy escapes, renewing your spirituality, for instance, so that you are fully charged for the onslaught of intense contact with challenging clients. The upshot is that a balanced and comprehensive plan for your self-care as a psychologist will require a dual focus: in your workplace and outside your workplace.
The Myth of the Invulnerable Psychologist
At this point in our article (and in our workshops), psychologists frequently nod their head in agreement but then attempt to convince themselves with the “But that’s not me” defense. Other practitioners, they argue, may confront professional distress and a paucity of self-care, but not me. We characterize this constellation of responses the myth of the invulnerable psychologist.
Decades of cumulative research rebut any illusion of invulnerability. The risks of practitioner distress are real, bordering on the “norm.” One study (Pope, Tabachnick, & Keith-Spiegel, 1987) found 59.6% of mental health professional’s surveyed acknowledged “working when too distressed to be effective” even though many of them acknowledge knowing that doing so is unethical. Another subsequent study (Guy et al., 1989) found that 74.3% of 318 psychologists reported experiencing substantial personal distress during the previous three years. Of those, 36.7% stated that it decreased the quality of patient care.
APA’s Colleague Advisory Committee has promulgated a Stress –> Distress –> Impairment –> Improper Behavior continuum. Not all distress leads to impairment, of course, but the research suggests that it frequently does. Each of us, all of us, are vulnerable to distress leading to impairment.
12 Self-Care Strategies: A Précis
Although research on psychologist self-care has not progressed to the point where randomized controlled trials (RCTs) have been conducted, there is a robust and growing body of empirical research. The research results, generated by diverse methodologies and numerous investigators, converge on 12 effective self-care strategies for psychologists (Norcross & Guy, 2007). And these same strategies probably prove effective for ordinary people as well; contrary to rumor, psychologists are people too. Below we outline these 12 strategies (see Norcross & Guy, 2007, for amplification and self-care checklists for each).
12 Self-Care Strategies
- Valuing the Person of the Psychotherapist. Self-care begins with self-awareness and personal commitment. Assess your self-care as you would a patient’s. Identify your vulnerabilities and sabotages. Writing, journaling, logging, or self-monitoring can track your progress. Secure honest feedback from loved ones and coworkers. Build on your successful self-care as opposed to simply adding new items onto the list. Make self-care a priority, not an indulgence.
- Refocusing on the Rewards. Re-experience the privileges of the profession. Notice the life rewards associated with clinical work. Feel the career satisfaction. Practice the mental set of gratitude. Recall Emerson’s words: “It is one of the most beautiful compensations of life that no man can sincerely try to help another without helping himself.”
- Recognizing the Hazards. Begin by saying it out loud: Clinical work is a demanding and often grueling enterprise. Affirm the universality of occupational hazards by sharing with colleagues. Beware the classic stressors of the “impossible profession”: emotional isolation, distressing patient behaviors, inhumane working conditions, physical exhaustion. Practice acceptance of the inevitable stressors. Cultivate self-empathy. Adopt a team approach.
- Minding the Body. Don’t overlook the bio-behavioral basics. Protect your sleep. Insist on bodily rest. Secure adequate nutrition and hydration during the day. Engage in regular physical exercise. Arrange for contact comfort and physical gratification. In your quest for sophisticated self-care, return again and again to the physical fundamentals.
- Nurturing Relationships. Cultivate a support network at the office: Clinical colleagues, supervision groups, clinical teams, office staff, community professionals, and mentors. Equally important, secure nurturance away from the office: spouse/partner, family members (including pets), friends, spiritual advisors, and Colleague Assistance Programs. Ask yourself repeatedly, “Who has my back?” Expectedly, psychotherapists find help relationships both deeply satisfying and highly effective for self-care.
- Setting Boundaries. Maintain boundaries (a) between self and others as well as (b) between professional life and personal life. During the day, schedule breaks, restrict caseload, refuse certain clients, insist on a livable income. Consider the 90% rule: only schedule up to 90% of desired hours to allow time for emergencies, family demands, and self-care. Balance client desires and self-preservation by saying “no” to patients, such as no shows, late cancellations, unpaid bills, and non-emergency intrusions in your life. Demarcate a boundary between work and private life with a transition ritual.
- Restructuring Cognitions. Monitor internal dialogue by your preferred method. Identify corrosive expectations about your performance as a clinician; for example, “I must be successful with my patients practically all of the time,” “I should not have problems; after all, I am a psychologist!” Manage problematic counter-transference reactions by self-insight, self-integration, empathy, anxiety management, and conceptualizing ability. Be gentle with yourself; shed the heavy burden of perfectionism that psychologists carry.
- Sustaining Healthy Escapes. Beware the prevalent unhealthy escapes of substance abuse, isolation, and sexual acting out. Practice absorbing errands and healthy diversions away from the office, e.g., travel, hobbies, humor, relaxation, exercise. How do you play? Restore yourself with vital breaks, days off, personal retreats, vacations, and mini-sabbaticals.
- Creating a Flourishing Environment. Harness the power of your work environment, thereby avoiding the fundamental attribution error (FAE) that your distress is solely your fault. Take an environmental audit of practice setting/office. Evaluate your work environment in terms of 6 key dimensions: work load, control, reward, sense of community, respect, and similar values. What is unsatisfactory and what can be done? High work demands plus high constraints is a toxic combination. Enhance the comfort of your work safety, privacy, lighting, ventilation, furniture, and aesthetics.
- Undergoing Personal Therapy. Practice what you preach by seeking personal psychotherapy. Confront your resistances not to pursue personal treatment. Return to personal psychotherapy periodically throughout the lifespan without shame. Supplement psychotherapy with self-analysis. As an alternative, obtain an annual satisfaction checkup. Integrate with other forms of self-development, such as creative arts, meditation training, yoga.
- Cultivating Spirituality and Mission. Reclaim your “mission” in life and in entering the profession. Cultivate wonder at the human spirit; it will enable you to pull hope from hell. Connect to the spiritual sources of your hope and optimism regarding behavior change. Confront squarely your own yearnings for a sense of transcendence and meaning. Become a citizen-therapist by merging your vocation with social activism. Let your life speak – manifest your core values in and outside the office.
- Fostering Creativity and Growth. Strive for adaptiveness and openness to challenges – the defining characteristics of passionately committed psychologists. Involvement in diverse professional activities (e.g., psychotherapy, assessment, teaching, research, supervision) balances your workload and expresses the full array of skills. Attend clinical conferences, read literature, and form study groups to access the life springs of continued education. Expect a lifetime of struggle for awareness and growth; self-renewal is an ongoing process, not a CE workshop.
Self-care is a personal challenge and ethical imperative that every psychologist – literally, every one – must consciously confront. That challenge can be surmounted by attending to the fundamental lessons gleaned from research and experience: Psychologists can effectively avail themselves of multiple self-care strategies unencumbered by theoretical dictates tailored to their unique resources, vulnerabilities, and environments. Be broad, flexible, and context-sensitive in replenishing yourself.
In advancing this argument, we are aware of two seemingly contradictory messages. On the one hand, we remind you of the ethical imperative of self-care – you should. The “you should” is our explication of the compelling research and experience that you should replenish yourself, in whatever forms and varieties that succeed for you, because it enhances you as a person and as a professional. On the other hand, we also advance a conflicting message of chill out and flexibility. The “chill out” is that we do not provide a set of universal prescriptions for self-care or demand that you must partake in specific techniques. As psychologists (and as people), we are inundated with the tyranny of the shoulds. The resolution to this apparent contradiction, like most dialectics, is to discover an internal self-care balance that accommodates both the ethical imperative and your personal preferences.
Our ardent hope in this article is that we have gently, collegially reminded you that our lives are works in progress and that you can practice self-care wholeheartedly, bringing your self fresh to each moment, each patient, and each day. You - and your clients - deserve no less.
*Adapted from Leaving It at the Office: A Guide to Psychotherapist Self-Care. (C) 2007 by John C. Norcross and James D. Guy. Adapted with Permission of The Guilford Press.
John C. Norcross, Ph.D., ABPP, is Professor of Psychology and Distinguished University Fellow at the University of Scranton, a clinical psychologist in part-time practice, and editor of Journal of Clinical Psychology: In Session. Author of more than 300 scholarly publications, his most recent books are Leaving It at the Office: A Guide to Psychotherapist Self-Care (with Jim Guy), Clinician’s Guide to Evidence-Based Practice in Mental Health and Addictions (with Tom Hogan and Gerry Koocher), and the 7th edition of Systems of Psychotherapy: A Transtheoretical Analysis (with Jim Prochaska). Dr. Norcross is a member of the Board of Directors of the National Register.
Jeffrey E. Barnett, Psy.D., ABPP, is a psychologist in independent practice in Arnold, Maryland and an Affiliate Professor of Psychology at Loyola College in Maryland. He is board certified in Clinical Psychology and in Clinical Child and Adolescent Psychology. A frequent author and lecturer on ethics, legal, and professional practice in psychology, Dr. Barnett is Associate Editor of Professional Psychology: Research and Practice and Editor of its Focus on Ethics section. He has served on the ethics committees of several professional associations. His most recent books are Ethics Desk Reference (with W. Brad Johnson) and Success in Mental Health Practice: Essential Tools and Strategies for Practitioners (with Steven Walfish). Dr. Barnett has been credentialed by the National Register since 1987.
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