The ethical imperative of self-care

The ethical imperative of self-care

It’s well known that mental health professions are associated with burnout. That risk increases when the general population faces prolonged stress, psychotherapy is in higher demand, and students’ needs—both remote and in-person—are more taxing. As providers continue shouldering their patients’ personal difficulties alongside their own, some psychologists argue self-care isn’t an optional add-on to a busy schedule but an ethical and moral imperative for the profession.

“We’re going through all the same things as our clients, yet we’re also holding space for them,” says Ana Rodriguez, PhD, a New York–based clinical psychologist and founder of the Self-Care Practice. “There’s so much new pressure on us that now more than ever it’s important that we support ourselves, especially if we have limited external supports.”

In addition to balancing their own stress with that of their patients and students, psychologists are facing unprecedented logistical challenges—working from home with families around, navigating new technologies involved in telehealth and remote teaching, and overcoming barriers to certain treatment methods.

For practitioners, many types of treatment are easy to deliver online; however, some services are more difficult to transform into successful remote solutions. For example, it may be difficult for clinicians to conduct exposure therapy for social anxiety when it’s not safe to go out in public, says Erica Wise, PhD, an ethics consultant and clinical professor emerita in the clinical psychology doctoral program at the University of North Carolina at Chapel Hill. “Depending on the specific focus of their practice, there may be complex technical layers involved in effectively translating evidence-based treatment to a virtual context, especially during a pandemic. Among many examples, this would apply to the work of psychologists who are treating people with obsessive-compulsive disorder, health and contamination fears or phobias, social anxiety, isolation, depression, and hoarding disorders,” Wise says. “And many of these problems are directly exacerbated by the pandemic.”

Even when patients don’t have complex treatment plans, psychotherapy can contribute to a risk of burnout. Psychologists can easily grow exhausted by addressing the same stress without new solutions, says Natalie Dattilo, PhD, a clinical psychologist at Brigham and Women’s Hospital in Boston. Before the pandemic, she says, patients presented with diverse problems; now, there’s not as much variety, and there are constant reminders about how difficult life is for everyone.

Black practitioners in particular face unprecedented, prolonged strain. Not only are Black individuals sorting through their own trauma with therapists in higher frequency, but White people are increasingly seeking support from Black professionals to work through issues of racism brought up by current events. “Now that there’s a White lens on these topics, there’s so much more demand for Black therapists to be talking about these issues we’ve been attuned to our entire lives,” says Ayanna Abrams, PsyD, a clinical psychologist and founder of Ascension Behavioral Health in Atlanta.

It’s important for psychologists to advocate for each other in material ways, says Laura Boxley, PhD, ABPP-CN, chair of APA’s Advisory Committee on Colleague Assistance (ACCA). “If I recognize that the well-being of my colleague is related to my leadership as division chair or director of training, it becomes my responsibility to set policy that protects the well-being of those that work for me,” she says.

The longer this stress goes on, the more likely it will surface in, and potentially interfere with, psychologists’ work. “Our personal wellness as psychologists really does impact our ability to help our patients or teach our students, because it directly interfaces with our competence,” says Wise.

For example, Abrams says, chronic stress can prompt people to feel disconnected from themselves and others, which can result in a less-attuned, less-sensitive, less-empathic therapist or professor. Stress can also impair treatment and teaching more directly: Under strain, it’s more difficult to exercise flexible and creative thinking, which Abrams says can in turn make it hard to help patients reframe their own thoughts—a crucial component of psychotherapy.

Even if a psychologist’s stress doesn’t noticeably interfere with treatment, patients and therapists are likely to catch on, says Brittany Avila, PhD, an instructor of psychology at the University of Nevada, Reno. A psychologist’s own neglect of self-care can prevent patients or students from taking suggestions for coping strategies seriously.

Clinicians and professors alike are responsible for modeling healthy emotions and behavior. In order to teach other people to engage in self-care during stressful periods, you have to exhibit positive behaviors yourself. “If you don’t model it yourself, they won’t take it seriously, or they just won’t know how to practice it,” says Avila, who regularly includes self-care practices as graded assignments in her courses.

Unfortunately, self-care is hard to come by, and that’s no different for psychologists. In a society that demands productivity, it can be tough—and even feel selfish—to fit new, self-focused practices into an already busy schedule. John Norcross, PhD, ABPP, a distinguished professor and the chair of the Department of Psychology at the University of Scranton in Pennsylvania and a clinical professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, encourages psychologists to reframe thoughts about self-care from a luxurious add-on to a professional imperative.

“Without self-care, there’s not good patient care,” Norcross says. “Integrating it into a routine becomes easier when you see it not as an additional burden but as part of your profession and craft.”

Here are some practical strategies for incorporating self-care into your life and work, as suggested by fellow psychologists.

The first step to ensuring your own well-being is monitoring your own stress levels and how they’re affecting you emotionally and physically. Rodriguez encourages prioritizing attention to one’s body: Ample sleep, a nutritious diet, and routine exercise are building blocks for well-being, and they support the ability to cope with stress.

To ensure these practices make it into your daily life, Wise recommends building a routine—scheduling time to break for meals, setting an alert to remind you of a reasonable bedtime, and leaving your shoes by the bed as a signal to go for a morning walk.

If you notice you’re feeling exhausted or disconnected at any point, resist the urge to power forward and, instead, tune in to your body. Mindfulness and meditation, which don’t have to be time-consuming, are both proven to reduce stress. If you find yourself tense during a therapy session, Norcross suggests adjusting your posture, moving your legs a bit in a way that doesn’t distract the patient, and taking a drink of water.

While self-care hinges on self-awareness, ensuring your own well-being is rarely as simple as sleeping a few more hours each night or eating more vegetables—especially for mental health professionals, Boxley says. For that reason, it’s important to adopt a comprehensive, individualized approach—and to avoid making self-care another to-do item, which can only compound feelings of burnout.

One way to do that: Go easy on yourself and celebrate any progress you make. You’ll be discouraged from sticking with your self-care routine if you aim for perfection. “These aren’t issues we ever get fully solved,” Wise says. “We’ll always be working on taking care of ourselves.”

If you tend to see self-care as a last-ditch effort to restore dwindling energy, try shifting your perspective, suggests Diane Bridgeman, PhD, a current board member of the Monterey Bay Psychological Association and former chair of ACCA. Rather than a reactive strategy, self-care should be seen as a comprehensive method of ensuring you—and your clients, staff, or students—thrive.

“How you define self-care is important,” she says. “It’s not just about being OK, but about flourishing, which requires de-stressing from everyday problems before they become serious.”

While self-care works best when it’s proactive, everyone’s practice is unique. Bridgeman encourages people to think through activities and relationships that spark joy. In what situations are you able to truly relax, reflect, and regroup? Aim to build those experiences into your routine alongside the building blocks of health, and remember that feeling guilty about not “sufficiently” following your self-sustaining routine is counterproductive.

In a national survey of psychologists, Bridgeman and clinical psychologist Daniel Galper, PhD, found that 72% of psychologists reported that their number one concern and personal and professional challenge was an “overly challenging work-life balance,” followed closely by “burnout or compassion fatigue.” Bridgeman says the risks for those challenges have only increased during COVID-19.

The demands on your time and attention may be more intense than ever, which is why it’s so important to limit how much you devote to work. If you work outside the home, Norcross suggests implementing a ritual that reminds you you’re done working when you enter your door. For example, you could change clothes, make a cup of tea, or turn on your favorite music—anything that turns off your “work” switch.

Now that many professionals are working from home, it’s even easier for work to trickle into hours normally reserved for rest or recreation. It’s inevitable that unexpected, timely tasks will pop up on occasion, but do your best to stick with a routine that separates work time from personal time. Consider adding a “fake commute” to your routine, which replaces the daily transition from work to home with walks, runs, and bike rides. And if you don’t have a dedicated home office, do your best to reserve your workspace for work alone.

On top of clarifying when you work, reconsider how much you work and with whom. For example, Abrams says she often receives emails from laypeople and professionals who want to tap into her expertise of racism-based trauma to overcome their own biases. Instead of educating people about the impact of racism by email, she recommends referring them to another therapist or an online resource.

You may also want to rethink your patient load and what types of patients you take on—especially if more work would interfere with your ability to take care of yourself and support your patients. “Many of us tend to give from what we have left, but it’s important for psychologists, especially marginalized populations, to offer to others from a place of rest,” Abrams says.

While it is important to promote balance in your work life, it’s not always easy (or possible) to control systemic factors that contribute to burnout, like gender expectations and division of labor at home and in the workplace, Boxley says. She advocates for people in positions of power to challenge the system that impedes equitable strategies for professional and personal well-being. “Top-down pressures are often not amenable to an individual just deciding to set boundaries,” she says.

It’s easy to isolate in chronic stress, especially when getting together with a friend or family member in person might not be a safe option. According to Rodriguez, feeling disconnected only compounds the original stress.

Prioritizing social interaction with friends and family can be helpful. But a professional outlet is meaningful, too. To take advantage of community support, you can also find a mentor, connect with your supervision group, or reach out to professional organizations such as APA or the Association of Black Psychologists for resources. Norcross suggests psychologists also occasionally go to therapy themselves when stress levels are high.

Samara Toussaint, PsyD, a clinical psychologist and founder of Path2Growth Counseling Services in Long Island, New York, says she began reaching out to colleagues for support after COVID-19 caused her practice to triple. “We’ve never dealt with so many compounded issues at once, and we really need to take the time to process what we experience with colleagues—people who understand,” Toussaint says. “That ‘me too’ can go a long way.”

Because your normal coping mechanisms might not be available right now because of the pandemic, look for creative ways to replenish your reserves. As easy as it is to zone out by scrolling news or social media when you’re tired, keep in mind that form of stimulation—which Wise says is called “hyperreality”—only serves to add stress. Instead, schedule events or activities you can look forward to that also encourage a sense of mastery, such as a home project or a physically distanced outdoor activity you enjoy.

Take advantage, too, of any self-care resources in your organization. According to Boxley, psychologists generally agree about the centrality of self-care, but they’re often not aware of resources already available to them, even as many organizations are stepping up to provide self-care opportunities for staff. Christopher Watson, PhD, deputy associate chief of staff of behavioral health at VA Pittsburgh Healthcare System, says he sees it as his responsibility to help his team provide the best clinical care to the veterans they work with. In addition to recharging opportunities at work—his organization streams virtual meditation sessions throughout the week—he encourages staff to use their leave when possible, or to shift around their schedules to better balance work with their kids’ distance learning.

“When we make these changes, it’s not just about convenience,” Watson says. “We always want to give our staff more opportunities to unplug so we can improve their coping and resilience and, as a result, improve the care they provide.”

At its core, Dattilo says self-care is about self-compassion. Practically, that means recognizing your own limits and, if necessary, letting yourself off the hook. For example, you may not accomplish as much as you did in previous years, and your patients or students may not make major strides, either. That’s OK. “Right now, it may not be about remission or absence of symptoms but about helping people improve their coping and resilience,” Watson says. The same applies for instructors: If you can preserve your students’ progress, you’re likely ahead of the curve.

Make every effort to home in on personal and professional successes, no matter how small. Norcross recommends running a mental video of successful cases you’ve worked with; you could also keep track of encouraging words from colleagues or students. “Most psychologists are achievement-oriented, and our minds are inordinately preoccupied with cases that did not go well,” he says. “We need to be reminded of the good work we’re doing.”

If you veer off course, don’t beat yourself up. Part of self-care is recognizing you can’t be on top of everything all the time. “We’re all people before we’re professionals,” Watson says. “And while stress might impact everyone in different ways, it’s impacing everyone in some shape or form—including psychologists.”

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