Self-Care for the Mental Health Practitioner

The Theory, Research, and Practice of Preventing and Addressing the Occupational Hazards of the Profession

Alfred J. Malinowski

• Publisher: Jessica Kingsley Publishers
• Year: 2014
• ISBN:
  9780857009319
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Dr. Alfred J. Malinowski's book provides a comprehensive resource on self-care for those working in the field of psychotherapy.

Beginning with an exploration of the role and duties of the mental health practitioner, Dr. Malinowski describes how the demands of practice can lead therapists to diminished psychological well-being. He explores the impact this can have and, through an examination of the latest research, reiterates the importance of the self-care of the practitioner. He presents a number of self-care techniques and strategies and explains how they can be applied to maintain psychological, spiritual, physical and social well-being. A final section explores the need for additional training for psychotherapists in the area of the hazards and self-care, both in graduate courses for future clinicians and to help experienced therapists continue learning and practicing self-care principles in their daily lives.

Highlighting the importance of self-care in the psychotherapy profession, this book will be of immeasurable value to psychotherapists, psychiatrists, psychologists, counselors, social workers, and other mental health professionals.

PART 1

Introduction to a
Demanding Profession

CHAPTER 1

Why Self-Care?

During the past decades, there have been a number of reports into the degradation of psychotherapists’ psychological well-being. In a national study involving 800 psychologists, 61% acknowledged being depressed, 29% mentioned feeling suicidal, and 4% reported having made a suicidal attempt (Pope and Tabachnick 1994). Another study conducted by Mahoney (1997) discovered 51 out of 155 therapists suffered from various symptoms related to depression and/or anxiety. Similarly, Gilroy, Carroll, and Murra (2002) found that out of 1000 counseling psychologists 62% were depressed and 42% experienced thoughts related to suicidal ideation. In addition, the American Psychological Association (APA) discovered in the 2009 APA Colleague Assistance survey that 40–60% of practicing psychologists had symptoms related to depression, anxiety, and/or burnout with 18% suffering with thoughts of suicidal ideation (APA 2010).

Gibson, McGrath, and Reid’s (1989) study of 176 social workers found that 89% of the participants had some type of symptoms related to job burnout, ranging from moderate to high intensity. Bohnert and O’Connell (2006) also reported that psychiatrists have faced high rates of suicide, divorce, and substance abuse. Finally, other studies have shown that psychotherapists have continued to suffer from such things as psychological distress, Compassion Fatigue (CF), and job burnout (Figley 2002; Hannigan, Edwards, and Burnard 2004; Maslach 1982). Of course, not every clinician suffers from such issues; the problem lies in not placing enough emphasis on self-care (Skovholt 2001).

So, self-care must be an imperative if the psychotherapist is not only to perform his/her duties at peak performance but also to maintain his/her psychological well-being. This attention needs to start with learning about self-care very early in a therapist’s educational process and throughout his/her career (Hill 2004; Myers and Sweeney 2005; Roach 2005; Skovholt 2001). In addition, Jones (2007) noted that learning and continually practicing self-care techniques early in the educational process helps the therapist maintain a focus on caring for his/her needs.

Throughout this book, terms such as psychotherapist, therapist, and counselor will be used interchangeably as they pertain to individuals who perform psychotherapy, unless otherwise indicated. The purpose of this chapter is to define self-care, ethical concerns related to self-care, and vulnerabilities as these pertain to the psychotherapist.

Self-care defined

So how can self-care be defined as it pertains to the mental health practitioner and his/her psychological well-being? This is a very important question that will affect the therapist throughout his/her career. According to Baker (2003b), self-care is the process a psychotherapist takes in understanding how to maintain his/her psychological well-being and applying this knowledge through many different means. Wise, Hersh, and Gibson (2012) describe self-care as not only being knowledgeable and applying this knowledge to ensure the therapist’s psychological well-being, but most importantly, it means being self-aware and cognizant of one’s weaknesses and limitations so the practitioner can effectively treat his/her clients. Likewise, Meyer and Ponton (2006) emphasize that the counselor must be knowledgeable, self-aware, and constantly applying these self-care principles to maintain a state of well-being.

Throughout this book, self-care will be seen as consisting of three parts. The first part involves knowledge and awareness of the hazards and self-care principles of the mental health practitioner. This knowledge and awareness should be learned very early in one’s training program and practiced throughout one’s career. The second part comprises the acceptance that the hazards and vulnerabilities of the clinician’s profession should be taken seriously. Therapists with this type of attitude know their weaknesses and limitations and are honest with themselves. These professionals know what to do and how to seek help when they have problems. The third part stresses the need to continually incorporate and practice self-care principles. This means that self-care should be always be at the forefront of a therapist’s mind.

So, self-care is the key and well-being is the goal. If the therapist does not take an active part in self-care, then he/she will not achieve a healthy psychological well-being (Linley and Joseph 2007). Being active may consist of participating in such activities as personal therapy and seeking supervision (Linley and Joseph 2007), mindfulness-based stress reduction (Shapiro, Brown, and Biegel 2007), being more self-aware (Baker 2007), the practice of meditation (Boellinghaus, Jones, and Hutton 2013), and/or participating in leisure activities (Dubrow 2011). Continually practicing activities such as these can buffer a counselor against stressors during the performance of his/her duties and help maintain a healthy well-being.

Coster and Schwebel (1997) describe well-being or well functioning as “…the enduring quality in one’s professional functioning over time and in the face of professional and personal stressors” (p.5). On the other hand, Carruthers and Hood (2004) report that well-being is a state that is characterized by the principles governed by positive relationships, personal growth, self-determination, a sense of purpose in one’s life, and self-acceptance. By contrast, Myers, Sweeney, and Witmer (2000, p.252) define wellness as:

a way of life oriented towards optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully within the human and natural community. Ideally, it is the optimum state of health and well-being that each individual is capable of achieving. (p.252)

One thing that is implied in maintaining a healthy psychological well-being through self-care is the ability to use coping strategies when the therapist is under stress (Stevanovic and Rupert 2004). Brucato and Neimeyer (2009) indicate that there is a difference between self-care and coping. While self-care emphasizes preventative measures a clinician takes before stress is felt, coping strategies modify the individual’s response once stress is encountered. So, according to this definition, self-care is the on-going activities the therapist performs to stay emotionally and psychology healthy, whereas a coping strategy is an activity or activities a clinician performs to stay calm during an emotional situation. An example of this is the therapist taking a deep breath and remembering to relax his/her body when interacting with a client threatening to commit suicide (Granello 2010).

There are a variety of strategies that the therapist can use in stressful situations. Parkinson (1997) reports that strategies such as humor, expressing feelings and emotions, and avoiding disturbing thoughts help in one’s daily life when the therapist’s caseload is focused on treating traumatized clients. Case and McMinn (2001) noted that prayer and meditation gave clinicians peace of mind when dealing with difficult clients. McAdams III and Foster (2002) showed that talking to family friends, peers, and supervisors relieved distress after a client’s suicide. Using positive talk in difficult situations was also shown as another way of keeping therapists calm (Stevanovic and Rupert 2004). However, not all counselors use positive strategies. Jordaan et al. (2007) have shown that some psychotherapists employ self-blame, self-distraction, and substance abuse to deal with the stress of their job. It follows, if a therapist does not constantly practice self-care, this can affect not only his/her psychological well-being but that of the client.

An ethical concern

How does the therapist’s practice of self-care affect clients and how is this an ethical concern? At first, self-care might not seem to be related to ethics, but indirectly it does relate (Wise et al. 2012). Many professional ethical codes stress the need for counselors and therapists to take certain actions if their psychological well-being degrades to a point that it is having a negative affect on their clients. The APA’s Ethical Principles of Psychologists and Code of Conduct, General Principle A: Beneficence and Nonmaleficence states: “Psychologists strive to benefit those with whom they work and take care to do no harm” (APA 2002, p.1063). In addition, Ethical Standard 2.06, “Personal Problems and Conflicts” dictates that psychologists are to refrain from treating clients when they become aware that personal problems are affecting their work-related activities (APA 2002). Counselors working with the American Counseling Association (ACA) and/or the American Mental Health Counselor Association (AMHCA) also have ethical codes mandating that their members terminate treatment and make referrals with clients when their mental health and psychological well-being are in question (ACA 2005; AMHCA 2010).

As professional practitioners involved in helping those who are suffering, psychotherapists have the responsibility to do no harm to their clients. This goes along with the Hippocratic oath to “do no harm.” Wise et al. (2012) note that a clinician who does not care for his/her psychological needs will eventually become impaired and this impairment will over time degrade the counselor–client’s relationship and produce a poor treatment outcome. Symptoms related to depression, substance abuse, anxiety, and/or job burnout can degrade the cognitive and psychological functioning of the practitioner where he/she can be uncaring and insensitive and may possibly even injure the client by his/her actions or by not acting (Gilroy et al. 2002; Mahoney 1997; Maslach 1982; Williams et al. 2010; Wurst et al. 2011). In this state of impairment, the therapist will not only be in distress, but be in danger of causing the client’s symptoms to worsen (Williams et al. 2010).

So how does one define impairment? Wise et al. (2012) define impairment as “…an objective change in the psychologist’s professional functioning that may result in ineffective services or cause harm to those with whom we work” (p.488). Swearingen (1990) defines an impaired psychiatrist as a professional who has a significant amount of difficultly in treating clients and performing duties in an objective and competent manner. Furthermore, the APA describes psychologists who are impaired as those who display poor professional functioning that is shown in their quality of work (Schwebel, Skorina, and Schoener 1996). Gilroy et al. (2002) write that impairment is a condition that may be shown by a therapist’s isolation from his/her colleagues and a diminished capacity to communicate effectively with clients. These definitions highlight that the psychotherapist is not only in distress, but that this distress has affected his/her psychological functioning in a way that clients could be harmed. In this context, distress is different than impairment. Munsey (2006) describes distress as the intense stress response a therapist experiences that affects his/her mood, thinking, and/or physical health in a way that may degrade professional functioning, whereas impairment is the condition that may impede psychological functioning to the point of bringing harm to a client. In fact, Kleespies et al. (2011) emphasize that if psychotherapists do not use self-care strategies during times of intense emotional distress, they may not only become impaired, but some therapists may become vulnerable to suicide ideation. Additionally, Sherman and Thelen (1998) discovered that there is a high positive correlation between distress and impairment. The question to ask is, at what point is the clinician impaired enough to bring harm to the client?

Many therapists may have been wondering “At what point is one impaired enough to justify reducing or terminating one’s caseload?” This may sound like a philosophical question with a variety of answers, but it is an important question with implications both for the therapist and for clients. Williams et al. (2010) developed a rating scale for therapists based on five levels of impairment on being depressed, where symptoms at Level 1 were mild and infrequent, and symptoms at Level 5 were intense and were felt frequently. A rating of 3.5 was described as being too impaired to practice. At this level, symptoms and intensities were described as being sad all day, at least once a week; crying at least once a week; feeling lethargic one day a week; and experiencing trouble sleeping at least once a week. Williams et al. (2010) indicated that the consequences of therapists experiencing these symptoms result in problems in concentrating and maintaining interest in clients, and also frequently being late, missing, and/or canceling sessions.

In the area of competence, psychotherapists of any profession should be knowledgeable and competent enough to know what their ethical responsibilities are in the area of impairment and self-care. In fact, the APA’s Ethical Standard 2.03, “Maintaining Competence” mandates psychologists to maintain and develop the knowledge of their duties and responsibilities of their profession (APA 2002). Goncher et al. (2013) emphasize that when self-care is taught early in one’s educational training and new techniques are learned and practiced later in one’s career, the quality of life can be much improved. Richards, Campenni, and Muse-Burke (2010) noted that when experienced mental health professionals learn new self-care techniques such as self-awareness and mindfulness their well-being is greatly enhanced and as a result they are able to treat clients more effectively. Therefore, competence is an ethical imperative in the area of self-care in order to prevent impairment.

A critical question that needs to be asked is, why do some therapists not seek help when they are impaired? Because mental health practitioners are in the profession of helping people in distress, some may be in denial that they could be impaired or that their condition could harm the client (O’Connor 2001). In another case (Barnett and Hillard 2001), a clinician might feel that if he/she sought help for some type of psychological distress, then family members, colleagues, friends, and/or clients might be critical of him/her. According to Bearse et al. (2013), several other reasons why some mental health practitioners might not get help when they are experiencing distress and impairment include difficulties finding an acceptable therapist, lack of time, financial reasons, or difficulty admitting distress.

Vulnerabilities

Self-care is not only an ethical concern, but it demands a psychotherapist to be aware and take care of his/her vulnerabilities. In this context, a clinician’s vulnerabilities can be within himself/herself. One type of vulnerability could be due to a therapist’s past history. Barnett (2007) discusses how a therapist with narcissistic traits in the form of “narcissistic injury” could negatively affect the therapeutic relationship between the counselor and client. Narcissistic injury is an event in an individual’s past where one’s “true” self was not responded to or validated and subsequently developed a “false” self (Winnicott 1960). In this case, Barnett states that a therapist who is unaware of this past injury could develop a false image of himself/herself to protect others from seeing his/her limitations and inadequacies. The danger here is that the clinician may not be himself/herself and therefore not meet the needs of the client because of fear of failure in the counseling process (Barnett 2007).

Another vulnerability a therapist must be aware of because of his/her developmental history is known as parentification. Parentification is a term used to describe the process of the child taking over the responsibilities of the parents, and in effect, parenting the parent (DiCaccavo 2006). In this case, the child cares for the parent(s) because of a disability or the parent just being irresponsible and relinquishing all parental duties to the child. The child then internalizes this process and may care for the needs of others more than his/her own, even at later points in his/her life (Nuttall, Valentino, and Borkowski 2012)...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Preface
• PART 1:Introduction to a Demanding Profession
• PART 2:Hazards of the Profession
• PART 3:Self-Care Dimensions
• PART 4:What’s Next?
• References
• Subject Index
• Author Index
• Also available