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By: Tracy L. Wityk University of Calgary, witykstk@shaw.ca
Linking Research to Educational Practice II, Symposium Paper
Posted by permission of University of Calgary
Table Of Contents
Ethical Guidelines Regarding Self-Care
Therapist Burnout
Why Psychologists Are Prone To Burnout
Ethical Issues Surrounding Self-Care And Burnout
This paper outlines and discusses burnout and the ethical imperative for therapists to engage in self-care. For the purposes of this paper, therapist refers to any mental health professional, including counsellors, social workers, psychologists, occupational therapists, and others. The literature focuses on counsellors and psychologists, but the issues are similar for all mental health professionals. When a particular study involved only a particular type of therapist, the researcher’s term for that professional will be used. Burnout is “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity” (Maslach, 1986, p. 61). Self-care consists of integrating one’s mental, emotional, physical, and spiritual well-being (Faunce, 1990, cited in Porter, 1995). Self-care is one of the primary methods of preventing and treating therapist burnout.
This paper begins by discussing Canadian, American, and Feminist Therapy ethical guidelines regarding self-care. The objective and subjective symptoms of burnout are described as a negative consequence of poor self-care. The vulnerability of therapists to burnout due to the characteristics of their occupation is also discussed. This paper discusses the ethical issues surrounding the consequences of burnout and the necessity of self-care. After providing a rationale for self-care, some common and effective methods for self-care are outlined and discussed. This paper intends to motivate therapists to engage in self-care and to provide therapists with enough information to begin, improve, or maintain such care. In this way, this paper hopes to improve the overall health of therapists and to help therapists become more ethical service providers.
Ethical Guidelines Regarding Self-Care
Canadian Code of Ethics And Conduct
Under the Canadian Code of Ethics, a therapist’s primary responsibility is to the welfare of the client (Canadian Psychological Association [CPA], 2000). Therefore, it is not surprising that it discusses self-care issues primarily as they relate to the welfare of clients. Self-care of the therapist is mostly an issue of responsible caring, one of the main ethical principles in the Code. According to this principle, therapists must “Evaluate how their own experiences, attitudes, culture, beliefs, values, social context, individual differences, specific training, and stresses influence their interactions with others, and integrate this awareness into all efforts to benefit and not harm others” (CPA, 2000, II.10). Self-awareness of how a therapist’s own pressures, issues, and stress influence clients helps to improve the care of those clients. Therapists must also “Seek appropriate help and/or discontinue scientific or professional activity for an appropriate period of time, if a physical or psychological condition reduces their ability to benefit and not harm others” (CPA, 2000, II.11). One takes time for oneself only if conditions are negatively influencing one’s professional performance. The College of Alberta Psychologists Code of Conduct states that “Psychologists shall not undertake or continue a professional relationship with a client when they know or should know that their judgment is impaired due to mental, emotional, or physiological conditions or as a result of pharmacological or substance abuse” (College of Alberta Psychologists, 1999, 10.1). It is unethical to practice while experiencing conditions that impair therapeutic performance. Therapists should “Engage in self-care activities that help to avoid conditions (e.g., burnout, addictions) that could result in impaired judgment and interfere with their ability to benefit and not harm others” (CPA, 2000, II.12). Again, one should engage in self-care and avoid negative conditions not for one’s own sake, but for the sake of others.
The Canadian Code of Ethics does not merely encourage self-care; it views lack of such self-care as unethical. Lack of self-care can lead to impaired judgment and performance. Such impairment is unethical as it can lead to harming clients (CPA, 2000). This impairment leads to questioning the competency of a therapist. Incompetent action is unethical as it is unlikely to be of benefit and likely to be harmful to clients (CPA, 2000). Although the Code does not specifically mention it, therapists should also practice self-care under the principle of respect for the dignity of persons. Certainly, this includes self-respect of the therapist as well as respect for clients. Therapists have a responsibility to clients, but they should carry out this responsibility in a manner that includes an awareness of and respect for their own needs. They must be aware of how stress affects their performance, should engage in self-care to mitigate negative effects of stress, and must discontinue practice if such stress significantly influences their work.
American Ethical Principles And Code Of Conduct
The American Ethical Principles and Code of Conduct (American Psychological Association [APA], 1992) also focuses on self-care issues primarily as they relate to the welfare of clients. This Code states under personal problems and conflicts that “psychologists have an obligation to be alert to signs of, and to obtain assistance for, their personal problems at an early stage, in order to prevent significantly impaired performance” (APA, 1992, 1.13.b). This is a fairly proactive statement that parallels the views of the Canadian Code of Ethics. However, there is no mention of the welfare of the therapist except as that welfare relates to work performance. This is a limited view of self-care. The American Code also prohibits therapists from practicing when they are significantly impaired, as this may harm clients (APA, 1992). Concern for others’ welfare and social responsibility, two main principles of this Code, may also be endangered by burnout resulting from a lack of self-care (Munroe, 1999). Burnout may decrease one’s desire and/or ability to be concerned about the welfare of others and of society as a whole. Self-care is of great ethical importance as it relates to many of the American ethical principles and rules of conduct. Self-care helps individuals to uphold the ethical principles of this Code.
Feminist Therapy
The Feminist Therapy Code of Ethics (Feminist Therapy Institute, 2000) is the only code that specifically focuses on self-care as it relates to therapist well-being. Most codes merely speak of self-care in terms of preventing impaired performance. This Code encourages self-care as an ethical practice relating to one’s personal health in addition to one’s professional health. The Feminist Code states that
A feminist therapist recognizes her personal and professional needs and utilizes ongoing self-evaluation, peer support, consultation, supervision, continuing education, and/or personal therapy. She evaluates, maintains, and seeks to improve her competencies, as well as her emotional, physical, mental and spiritual well-being. (Feminist Therapy Institute, 2000, IV.C).
Furthermore:
A feminist therapist engages in self-care activities in an ongoing manner outside the work setting. She recognizes her own needs and vulnerabilities as well as the unique stresses inherent in this work. She demonstrates an ability to establish boundaries with the client that are healthy for both of them. She is also willing to self-nurture in appropriate and self-empowering ways. (Feminist Therapy Institute, 2000, IV.E).
Feminist therapy expects therapists to take care of themselves in order to ensure that they do no harm to clients (Porter, 1995). However, the needs of the therapist are also important. Therapists must balance their own needs against those of the client (Porter, 1995). This ethical perspective respects and balances the personal and professional lives of therapists. Feminist therapy emphasizes creating a positive environment rather than simply maintaining a harmless environment (Porter, 1995). Self-care is not just a method of preventing work impairment, but is also a way to improve the overall therapeutic environment. There is a focus on education and prevention rather than correcting abuses after they occur (Porter, 1995). Feminist ethical perspectives have a preventive and holistic view of self-care and therapist well-being (Porter, 1995).
Therapist Burnout
As stated previously in this paper, burnout is “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity” (Maslach, 1986, p. 61). Burnout appears to be a response to chronic sources of interpersonal and emotional stress at work (Maslach, 1986). Emotional exhaustion is the perception of emotional overextension and of one’s contact with others draining one’s energy (Maslach, 1986). Emotional exhaustion includes feelings of apathy, entrapment, dissatisfaction, hopelessness, helplessness, nervousness, irritability, discouragement, and emptiness (Muldary, 1983). Depersonalization is an unfeeling and hardened response toward others (Maslach, 1986). Reduced personal accomplishment is a decrease in one’s sense of competence and achievement in one’s work with others (Maslach, 1986). Sources of burnout may be personal, interpersonal, and/or organizational (Maslach, 1986). Burnout influences all physical and emotional aspects of individual functioning (Guy, 1987). The exact manner in which burnout is experienced and manifested differs across individuals (Muldary, 1983).
There are many objective signs and symptoms of burnout (Patrick, 1981). These include increasing overwork, skipping rest and food breaks, delaying or canceling vacations, a declining sense of humour, fatigue, irritability, increased susceptibility to illness, increased physical complaints, social withdrawal, changes in job performance, and self-medication. Patrick (1981) lists many subjective signs and symptoms of burnout as well. These include emotional exhaustion, decreased self-esteem, feeling trapped, emotional withdrawal, depression, intensified difficulty in receiving anything from others, boredom, low motivation, increased frustration, feelings of failure, and increased isolation.
Therapist burnout closely relates to self-care. Lack of self-care increases one’s risk for burnout (Patrick, 1981). Learning to take positive action when symptoms begin to appear is essential to the process of preventing and treating burnout (Patrick, 1981). One effective method for such positive action is self-care. As it is often difficult to change the system within which one works, self-care strategies are often the most ready means of reducing burnout risk (Patrick, 1981). A well-designed program of self-care is probably the best intervention for preventing and treating burnout (Guy, 1987).
Why Psychologists Are Prone To Burnout
Psychotherapy taxes the emotional and physical resources of the therapist (Whitfield, 1980). There are several job characteristics of psychotherapy that fuel the burnout process (Patrick, 1981). These are repetitive contact with people, intense interpersonal contacts, long-term involvement, and the giving role. Therapists may feel discouraged and see the world in a negative light as they are constantly surrounded by people and their problems. Therapists may not receive adequate positive reinforcement for the work that they do. Clients do not have to give anything back to the therapist in terms of reward or gratification (Patrick, 1981). Therapists may not feel valued by clients, and feeling less valued may lead to burnout (Patrick, 1981). Perhaps the most stressful characteristic of a therapist’s job is that he/she must deal with the possibility of client suicide on a constant basis (Whitfield, 1980). Being a therapist can be rewarding, but it also carries many occupational risks that may lead to burnout.
Beliefs and expectations of the therapist, and of others, also increase therapists’ risk of experiencing burnout. Other people’s pain can make therapists feel anxious and helpless (Jaffe, 1986). Not only do therapists observe other people’s pain, there is an obligation and expectation for them to fix the pain or make it go away (Jaffe, 1986). There are two myths that lead to extra pressure in health care settings (Jaffe, 1986). The first is that therapists should submerge their personal needs, as they have no place in health work. The second is that the emotions of the workers are not relevant. Women therapists may be especially prone to burnout as they often continue their giving and helping role at home (Jaffe, 1986). They often do not have a source of nurturing for themselves, and frequently do not see the need for self-care (Jaffe, 1986). Therapists undergo training to become independent (Kilburg, 1986), which may increase their isolation and decrease their social support in times of stress. They also feel pressure from the expectations of colleagues, consumers, friends, and family (Kilburg, 1986). Common beliefs and expectations about therapists and the work that they do act to increase the pressure and stress that they experience, which increases their risk for burnout. These beliefs and expectations also increase one’s risk for burnout as they create barriers to seeking help and engaging in self-care, which can help prevent and treat burnout.
Overall, studies suggest that the prevalence of distress and impairment among psychologists is at least at the level of the general population (Nathan, 1986). However, only a minority of therapists appear to experience burnout or impairment severe enough to noticeably interfere with their clinical work or personal lives (Guy, 1987). Mahoney (1997) studied the personal problems and self-care patterns of psychotherapists. Less than half the sample of psychotherapists reported emotional exhaustion, which was the most frequently reported problem. Only one third reported any anxious or depressive episodes over the previous year. Most engaged in some form of self-care. These data suggest that the psychotherapist may be happier and less troubled than previous research concluded. This does not indicate that burnout is any less problematic for those therapists that do experience it. These data do suggest, however, that therapists are beginning to engage in more self-care with positive results.
Therapists should be aware of this proneness to burnout and learn about how to engage in self-care to prevent its negative consequences. They need to learn the importance of balancing their personal and professional lives (Munroe, 1999). Therapists need to follow their own advice and engage in the same beneficial self-care activities that they suggest to their clients in order to maintain their personal and professional well-being. One should recognize the hazards of psychological practice (Norcross, 2000) and engage in self-care to deal effectively with such hazards.
Ethical Issues Surrounding Self-Care And Burnout
Burnout produces symptoms that threaten ethical therapeutic practice. Self-care is one method of preventing and treating therapist burnout. As such, self-care is a part of ethical practice. Self-care has three main functions (Porter, 1995). It protects the client by reducing risks associated with ethical violations. Self-care promotes and models growth and well-being, which enhances therapy with a client. Self-care also provides protection for the therapist from occupational hazards. These functions of self-care help uphold ethical principles and standards for therapists.
Protection Of Clients From Ethical Violations
“Martyrdom begets poor care of clients, not sainthood.” (Porter, 1995, p. 253) Giving of oneself for the sake of others is admirable. If one does not balance this giving with self-care, it can lead to burnout, which may result in ethical violations. Poor therapist self care is associated with a greater risk of ethical breaches due to increased personal vulnerability, reduced self-monitoring and poorer judgment (Keith-Spiegel & Koocher, 1985, cited in Porter, 1995). Poor self-care can result in isolation, poor judgment, grandiosity, self-deception, and an increased risk of getting one’s needs met through the therapeutic relationship (Porter, 1995). Self-care can protect clients from ethical violations resulting from therapist burnout.
Incompetent Practice
All psychological ethical codes state that one needs to be competent in providing care to clients. Incompetent care is unethical as it is likely to lead to harm and unlikely to benefit clients. Burnout can lead to decreasing the quality and effectiveness of care a therapist provides to clients. Such a therapist is incompetent and unethical. Most codes also state that if the quality of care a professional provides becomes impaired, it is unethical for that professional to continue practicing. Such professionals should take time off and seek help. Self-care is one method of seeking help that may prevent such impairment before any incompetent practice occurs.
Self-care is essentially a prerequisite to providing competent care. In psychological practice, the self is an instrument of therapy that needs to be cared for (Guy, 1987). If one does not care for this instrument, then therapy is less likely to be of high quality or efficacy. Therapists must attend to their own personal well-being in order to function effectively in their role as caregivers (Guy, 1987). In psychological treatment, one’s emotional state closely relates to one’s efficacy (Knutsen, 1977). Effective therapy is possible only when one is emotionally stable, physically alert, and open to the awareness of one’s own feelings as well as those of the client (Whitfield, 1980). Therapist well-being positively relates to the therapeutic outcome of a client (Porter, 1995). Self-care is one method of attending to one’s personal needs that one must meet in order to provide effective therapy. Therapists that do not meet their personal needs are likely to have difficulties in providing effective therapy, which makes them both incompetent and unethical.
Burnout can result in conditions that negatively influence the quality of care a therapist provides to clients. A decline in enthusiasm and commitment may result from therapist burnout. When enthusiasm and commitment decline, there is also a decline in the overall motivation to provide quality care (Muldary, 1983). Therapists may have difficulty in paying attention, concentrating, solving problems, and making decisions (Muldary, 1983). These difficulties are likely to lead to a poorer quality of services and poorer therapy outcome (Muldary, 1983). Self-care may result in an improvement of such cognitive processes that relate to the quality of therapy provided. Burnout significantly negatively influences worker productivity, job performance, morale, satisfaction, attitude, and use of benefits (Patrick, 1981). This is likely to negatively influence the effectiveness and quality of care provided to clients. Burnout is also associated with more inhumanistic counseling practices, more behaviour that is aggressive towards clients, and more mistakes at work (Maslach, 1986). Such behaviours are not merely incompetent; they are clearly harmful and disrespectful to clients. Some negative coping strategies that people engage in to fight burnout are substance use, psychophysiological illness and collapse, escape, avoidance, and defense mechanisms (Muldary, 1983). Therapists engaging in such strategies are less likely to benefit clients and more likely to harm clients. Self-care can replace negative coping strategies with healthy ones that benefit both therapists and clients. Burnout leads to decreases in the quality of care given to clients, and as such, is unethical.
Boundary Violations
Faunce (1990, cited in Porter, 1995) states that therapists violate boundaries when they have not met their own needs. This situation can arise from lack of therapist self-care to meet his/her personal needs. Lack of self-care can result in dual relationships (Lerman & Rigby, 1990, cited in Porter, 1995), which are fraught with ethical problems. A lack of therapist self-care may foster range of boundary violations, from being overly friendly to sexual exploitation (Porter, 1995). A therapist may meet certain needs by fostering excessive dependency in his/her clients, leading him/her to feel gratified and needed (Porter, 1995). One needs to develop a life outside of work in order to prevent oneself from being overly dependent on certain responses from clients and colleagues (Jaffe, 1986). Overinvolvement may help therapists to avoid confronting issues in their personal lives or to help satisfy unmet needs (Porter, 1995). Overinvolvement may also lead to overidentification with a client and a resulting lack of objectivity (Porter, 1995). Boundary violations are problematic as they may result in exploitation of the client by the therapist, lack of therapist objectivity, and confusion between the therapist and client regarding expectations (Pettifor, lecture, 2002). All of these factors might negatively influence the client and the therapeutic outcome. Therapists have an ethical responsibility to protect clients from boundary violations resulting from their own unmet needs. An excellent way of meeting one’s own needs is through self-care.
Connection To Clients
Burnout can severely disrupt the therapeutic relationship that a therapist has established with a client. Emotional unavailability may result from lack of therapist self-care, and may interfere with the empathic connection between therapist and client (Porter, 1995). Burnout includes depersonalization, which may lead to withdrawal from clients or rude, insensitive, and/or inappropriate behaviour towards clients (Maslach, 1986). A decline in enthusiasm and job satisfaction, which can result from burnout, may lead to a loss of empathy, caring, and respect for clients/patients (Muldary, 1983). As therapists burn out, they begin to care more about themselves and less about others (Muldary, 1983), which is also certain to affect the therapeutic relationship. Therapists may put client needs behind their own by being late, failing to maintain common courtesies, and/or answering phone calls during therapy sessions (Whitfield, 1980). Burnout may also lead to difficulties in listening to others (Muldary, 1983). Defensive avoidance of emotions due to burnout can result in excessive intellectualization of treatment, advice-giving, interpretations, and/or lecturing (Whitfield, 1980). Therapists experiencing burnout are also more likely to express anger towards patients/clients (Muldary, 1983). If one does not care for oneself physically, one may be generally fatigued and even fall asleep during sessions (Whitfield, 1980). Negative attitudes towards clients, colleagues, self, and environment may develop as a result of burnout (Muldary, 1983). Lack of self-care also contributes to power abuses with clients (Porter, 1995). Chronic stress and burnout increases the chance of client/patient neglect (Muldary, 1983). All of these factors would certainly negatively affect the connection and relationship therapists have with clients. These conditions that can result from burnout are unethical as they do not display adequate respect for clients. Such a poor connection between therapist and client is likely to disrupt a client’s faith in therapy, trust in the therapist, and overall therapeutic outcome. Therapists with this type of connection with clients are not able to provide effective or competent service. Burnout is clearly unethical as it creates conditions that may violate the ethical principles of respect for the dignity of clients and responsible caring.
Promotion Of Client Self-Care
One of the most important functions of therapist self-care is that it fosters client self-care. The therapist acts as a role model, models self-care strategies, and validates the importance of the client’s needs, thoughts, and emotions through their own self-care (Faunce, 1990, cited in Porter, 1995). Therapist self-care also increases the hope and faith of clients as they can see that therapists are able to heal themselves (Guy, 1987). Benefits derived from client self-care are likely to enhance therapy, improve treatment outcomes, and improve client functioning in all areas of his/her life. This promotion of health and well-being is ethical as it benefits the client in a respectful manner.
Protection Of Therapist From Occupational Hazards
Psychologists are prone to burnout due to particular characteristics of their occupation discussed previously in this paper. One needs to be concerned about client welfare, but one must also consider the welfare of the therapist. It is ethical to protect oneself from occupational hazards of conducting therapy. Conducting therapy is stressful, and this stress can have negative effects on therapists. Research has linked job stress to heart disease, ulcers, depression, anxiety, dissatisfaction, tension, and low self-esteem (Maslach, 1986). Self-care can protect therapists from these conditions by reducing stress and helping one to deal with stress more effectively. Burnout also produces a sense of emptiness, aloneness, frustration, failure, and fatigue (Patrick, 1981). These feelings and conditions can certainly influence relationships with clients as well as the therapy conducted with them. However, one should also engage in self-care to prevent these symptoms of burnout for the sake of the therapist. These feelings and conditions are negative, painful, and can be destructive to more than the professional health of the therapist. They are likely to affect a therapist’s physical, cognitive, emotional, social, and spiritual well-being. Self-care is ethical as it helps to protect therapists from hazards associated with their work and as it can improve many aspects of their lives in a holistic manner.
Methods of Self-Care
Therapist self-care is an ethical necessity. There are many methods, strategies, and techniques available to therapists to help them achieve their self-care goals. Guy (1987) suggests that reducing stress and dissatisfaction while taking proactive steps to rejuvenating therapists on an ongoing basis is the most useful approach to preventing and treating burnout. Self-care is one method of achieving these goals. Therapists should take steps before problems occur to increase available coping resources in preparation for the causes and symptoms of burnout (Guy, 1987). Therapists need to be motivated to ensure a balanced and healthy lifestyle (Guy, 1987). They need to take aggressive measures to reduce or eliminate those personal and environmental stresses which have the potential to negatively influence their personal and professional lives (Guy, 1987). Immediate changes necessary to manage burnout include: self-monitoring and awareness of a problem, identification of stressors, accurate appraisals of transactions with the work environment, commitment to action, and acquiring or enhancing personal coping resources (Muldary, 1983). It is important to have a variety of self-change skills and one should embrace multiple strategies, even if they are from diverse theoretical orientations (Norcross, 2000). This section of the paper will outline and discuss various methods of self-care in greater detail.
Self-Awareness
Self-awareness is central to preventing burnout (Patrick, 1981). One of the most important steps in managing burnout is recognizing the signs and symptoms of burnout (Muldary, 1983). Self-care requires self-awareness: one needs to know when one feels stressed and when it is time to seek help (Maslach, 1986). Awareness of how one tends to respond to stress also provides a database against which to measure change and growth (Muldary, 1983). Self-awareness is the first step in self-care that combats burnout (Norcross, 2000). Without self- awareness, therapists may never be motivated to engage in self-care to help prevent and treat burnout.
Physical Health
Improving and maintaining one’s physical health is an important part of self-care. Relaxation, exercise, and diet are frequently mentioned methods of self-care that help prevent and treat burnout. When one is operating under optimal physical and psychological health, one is better able to handle stress (Maslach, 1986). Physical health and exercise, as well as adequate opportunities for rest and relaxation are essential for maintaining a sense of stability and well-being (Guy, 1987). Therapists have demanding jobs and it is important for them to have time for recharging, rest, and relaxation (Maslach, 1986). Relaxation reduces fatigue and aches, decreases stress responses, replenishes energy, enhances the ability to fall asleep and sleep soundly, and facilitates an overall sense of calmness and well-being (Patrick, 1981). Meditation is also an excellent form of self-care as it helps people relax by slowing the frantic pace of living (Patrick, 1981). Research has shown that adequate exercise and relaxation are effective in reducing burnout among therapists (Guy, 1987). A well-balanced program of entertainment and exercise has led to less burnout among therapists (Guy, 1987). Diet is also important as it increases one’s energy and makes it easier for one to relax (Muldary, 1983). One needs to pay attention to one’s physical health through preventive care, such as going to a doctor and dentist regularly for check-ups (Patrick, 1981). Improving and maintaining one’s physical health is an effective self-care method as it increases one’s energy, sense of well-being, and ability to deal with stress effectively.
Leisure Activities
Balancing professional activities with a life outside of work is an important form of self-care (Norcross, 2000). Therapists often do not receive direct feedback and gratification from their work (Patrick, 1981). Therefore, it is essential to have sources of gratification other than work, such as reading, watching movies, and sports (Whitfield, 1980). Taking part in an enjoyable activity also replenishes one’s energy resources, reduces tension, and makes relaxation easier (Patrick, 1981). A reduced sense of accomplishment resulting from burnout may lead to even more extreme feelings of inadequacy, failure, depression, and low self-esteem (Maslach, 1986). Satisfaction gained through leisure activities may help alleviate many of the subjective symptoms of burnout, including emotional exhaustion, decreased self-esteem, feeling trapped, emotional withdrawal, depression, boredom, and increased isolation. Engaging in leisure activities is an important part of any self-care program and has many beneficial effects in preventing and treating burnout.
Coping Strategies
Individuals with adequate coping strategies are less likely to burn out (Patrick, 1981). Developing and using coping strategies is therefore an important method of self-care. Coping strategies are the “ability to draw on emotional, physical, and social resources that allow one to avoid the adverse impact of stress.” (Patrick, 1981, p. 46). When dealing with burnout, one may need to engage in direct coping strategies, including confronting the source of stress, changing oneself, and changing the environment (Muldary, 1983). Some concrete coping strategies include: reappraisal of goals, time management, acknowledging vulnerabilities, compartmentalizing life and work, self-reinforcement, and a change of attitude (Muldary, 1983). Training in assertion and conflict resolution may also help people cope with stress due to interpersonal relationships (Patrick, 1981). Developing and engaging in coping strategies is one self-care method that acts directly to prevent and treat burnout.
Support Network
In dealing with occupational stress, one needs support from self, personal relationships, and work structure (Jaffe, 1986). One needs a support network where one can express one’s emotions. Expression of emotions decreases the isolation and loneliness that often result from burnout (Patrick, 1981). Emphasizing the interpersonal element in one’s self-care and utilizing various helping relationships seems to be beneficial (Norcross, 2000). Healthy friends and family are an extremely important support to have (Whitfield, 1980). Seeking personal therapy is a method of gaining support that a majority of therapists have engaged in (Norcross, 2000). There are also many support strategies that an organization may use to prevent and combat burnout in its employees (Patrick, 1981). These include having a clear and consistent communication style, planning self-care programs, assessing burnout, educational opportunities, methods of acknowledgment, psychological support options, mental health days, and fitness programs. Many professional groups have developed programs for impaired professionals, but this is not yet the case in the field of psychology (Nathan, 1986). Developing and using a strong support network is one component of self-care that is likely to help prevent and treat burnout.
Modifying The Work Environment
One’s work environment can contribute to burnout. Modifying one’s work environment is another useful way of combating burnout through self-care. When possible, therapists should engage in stimulus control (Norcross, 2000). Stimulus control consists of manipulating antecedents and consequents to increase the probability of desired behaviours occurring (Walker, Greenwood, & Terry, 1994). The frequency with which therapists modify their environments to work for and not against them using stimulus control consistently correlates with therapist effectiveness (Norcross, 2000). One may not need to work harder, but smarter (Maslach, 1986) to deal with burnout. One can achieve this through changing work patterns, styles, and/or routines (Maslach, 1986). Diversifying one’s professional activities is another method of self-care (Norcross, 2000), as job monotony can contribute to burnout (Patrick, 1981). Poor work relations, little or no work sharing, a lack of social feedback, no legitimized time out from client contact, and little or no peer support correlated highly with social service worker burnout (Pines & Kafry, 1978, cited in Leon, Altholz, & Dziegielewski, 1999). Therefore, good work relations, work sharing, feedback, time away from clients, and peer support should be in place to counteract burnout. Patrick (1981) outlined several personal strategies to use to prevent and combat burnout in health care settings. These include peer support groups, peer contracting, minivacations, setting limits, acknowledgment, personalizing one’s workspace, and decompression periods. Another method of self-care is to appreciate the rewards of being a therapist (Norcross, 2000). The psychology profession brings joy, meaning, growth, excitement, and vitality to both the therapist and the client (Norcross, 2000). Modifying how one interacts with one’s work environment and focusing on the positive aspects of one’s work are beneficial components of therapist self-care.
Cognitive Factors
Many cognitive factors influence one’s experience of burnout. Individuals with an external locus of control may feel helpless and powerless, and may thus be more susceptible to burnout than those with an individual locus of control that may take a more active stance in dealing with stress (Patrick, 1981). Changing one’s attitudes towards responsibility and control for one’s experiences may be one method of self-care to prevent and treat burnout. Unrealistic expectations may also increase one’s risk for burnout. Effective self-care may include setting more realistic expectations and goals for oneself (Maslach, 1986). Goal setting can also help reduce burnout because it acknowledges personal accomplishments (Patrick, 1981). One should avoid wishful thinking and self-blame wherever possible (Norcross, 2000). Wishful thinking reduces problem solving and accentuates distress; self-blame causes more distress and may paralyze the therapist’s adaptive resources (Norcross, 2000). Therapists should examine and perhaps modify their cognitions that relate to burnout as part of their self-care efforts.
Self-Care For Graduate Students
Guy (1987) reviewed the literature pertaining to reducing stress and burnout in graduate school training for future psychotherapists. Play, recreation, reading, creative activities, time off, and exercise significantly increased the overall life enjoyment of students. These self-care activities also decreased the self-perceived stress and tension of the students. A meaningful support network was beneficial in moderating the impact of stressors inherent in training to become a psychotherapist. Maintaining a life outside of school provides students with a balance that is necessary for coping with graduate training stress in a useful fashion. A combination of leisure, relaxation, exercise, and support self-care methods helped students deal with stress that may have otherwise led to burnout.
Summary
Burnout threatens the ethical principles of respect for the dignity of persons, responsible caring, concern for other’s welfare, and responsibility to society. Most ethical codes focus on burnout and self-care as they relate to client, and not therapist, welfare. Feminist therapy has the most holistic view of self-care and burnout. It encourages self-care as an ethical practice relating to one’s personal and professional health. Feminist ethics focus on education and prevention rather than correcting abuses after they occur (Porter, 1995). Burnout affects all aspects of a therapist’s functioning. Its effects are pervasive and ethically dangerous. Its symptoms can lead to incompetent care, boundary violations, disrupted therapeutic relationships, and various health problems for therapists. Self-care effectively reduces these negative effects that are threats to ethical practice. Some methods of self-care are self-awareness, physical health, leisure activities, coping strategies, support networks, modifying one’s work environment, and various other cognitive methods. Self-care protects clients from harm, promotes client self-care, and protects therapists from occupational hazards and stress (Porter, 1995). It improves the functioning and health of all individuals involved in all areas of their lives. Therapist self-care forms a foundation for health and ethical psychological practice.
Discussion
There are troubling issues in the ethics of burnout and self-care. It is troubling that most ethical codes do not mention the welfare of the therapist when discussing burnout and self-care (Munroe, 1999). It is potentially dangerous to continue revering the image of dedicated, self-sacrificing workers who never give a care to their own needs (Stamm, 1995). This view may perpetuate burnout and lack of therapist self-care. There is beginning to be a shift away from a therapist only being concerned with the care of the client, regardless of the cost to him/herself (Porter, 1995). The welfare of the therapist for his/her own sake is increasing in ethical importance. Self-care implies that the individual is responsible for preventing the problem and that it is the individual’s problem when it does occur (Stamm, 1995). Therapists often receive blame for stress responses, rather than seeing stress as a natural response and as an opportunity for exploration and dialogue (Munroe, 1999). It is the responsibility of each individual therapist to engage in self-care. However, there is only so much that one can achieve without changing the environment in which one operates. Employers and organizations should move to make an effort to support therapists in their battle against stress and burnout. The mental health profession needs to expand its views of burnout and self-care to include therapist welfare and organizational support.
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This paper is the basis for a presentation, adapted for an audience comprised primarily of educators, at the Linking Research to Professional Practice research symposium held at the University of Calgary, July 5-7, 2002.