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This is an intermediate course. Upon completing this course, mental health professionals will be able to:
This is the third course in this three-part series. Portions of this course are adapted from the book, Leaving It at the Office: A Guide to Psychotherapist Self-Care, © 2018 by John C. Norcross and Gary R. VandenBos and reprinted by arrangement with Guilford Press.
The information in this course is based on the most accurate information available to the authors at the time of writing. Self-care research and practice grow continuously, and new information may emerge that supersedes these course materials. This course will provide clinicians with an understanding of self-care and equip them to experiment with additional self-care methods. Doing so may provoke novel feelings or unsatisfying results for some readers. There are no known severe risks of engaging in clinician self-care.
Note: While you may choose to read the courses in this series singly or in any order, we believe it will prove important to complete them in sequential order. The first course in this series, Ethics of Self-Care: Where the Personal is the Professional, serves as the foundation for all three courses. The second course, Therapist Self-Care: Personal Relationships, Cognitions, and Behaviors,covers self-care at the office as well as away from the office. This third and final course offers a wide range of mindful related practices for the self-care of the therapist. We hope that your spirit and practice will be touched as you study the information provided here and that these self-care strategies will awaken and direct your sensitivities to your personal and professional identity as a psychotherapist.
Mindfulness is of emerging prominence in psychotherapy, and its supportive research demands its own use by and for the psychotherapist. In this course, we canvass for self-care consideration a bevy of mindfulness-related practices: taking a moment, practicing mindfulness, using meditative anchors, adding meditation, cultivating self-compassion, expressing gratitude, and honoring transitions. It is way more than taking yoga classes on the weekend. The course then minds the body of the practitioner by addressing sleep, rest, nutrition, exercise, and human contact. Finally, we move to minding the external environment of the mental health practice, including the physical environment, sensory awareness, work safety, business support, and systems of self-care. The course features pan-theoretical methods of self-care, highlights representative research, infuses examples from master therapists, and concludes with a practical self-care checklist.
“It is better to conquer yourself than to win a thousand battles. Then the victory is yours. It cannot be taken from you.”
– Buddha
Mindfulness integrates several self-care strategies: It minds the body, sets boundaries between your client focus and your self-care, restructures your foraging squirrel or monkey brain thoughts, and represents at least a momentary escape from your usual professional activity.
Of course, mindfulness is hardly new. As a frame of mind, meditation has been with us for as long as humanity; as a formal practice, meditation dates back to India in 1500 BCE. Even the Buddha himself learned meditation from two teachers.
Some form of mindfulness has been advanced by multiple theoretical persuasions via different labels (Geller, 2017). Freud’s observing ego involves a calm and detached mental state with impartial awareness of all that occurred during psychotherapy. Reik’s (1948) “listening with a third ear” entails a similar presence. Centeredness or groundedness in humanistic traditions and contact in gestalt therapy capture the full, moment-to-moment connection with the totality of others, self, and situation. However, while the idea of mindfulness is not new, its research base and creative applications to self-care probably are.
What do we mean by mindfulness? In the simplest of terms, paying attention in a particular way: purposefully, in the present moment, and nonjudgmentally (Kabat-Zinn, 1990). As self-care, mindfulness helps us to sense and experience subtler aspects of emotion in the daily process of living. It increases a gentle awareness of affects, thoughts, and ways of responding to stress and strain – as well as pleasure.
All psychotherapists already possess some mindfulness skills. It would prove nearly impossible to complete graduate training in clinical work without some degree of self-observing and self-reflecting skills. But there are obviously individual differences, and therapists array themselves across a continuum of mindfulness as a basic orientation and skill.
Most therapists begin sessions in a mindful manner, but they frequently lose their center as patient conflict, affective explosions, and countertransference envelop the session. Hence our emphasis on maintaining mindfulness throughout the session, throughout the clinical day, and throughout your life.
In this course, we recommend for your self-care consideration a bevy of mindfulness-related practices: taking a moment, practicing mindfulness, using meditative anchors, adding meditation, cultivating self-compassion, expressing gratitude, and honoring transitions and rituals. As you participate in this course, please join us in conceptualizing mindfulness as a pan-theoretical, evidence-based set of skills and capacities designed to nurture yourself; it is way more than yoga classes on the weekend.
The life of a mental health professional generally proves hectic and complex. If you have a partner, children, parents, family, friends, and a clinical practice, then you are even busier. Something always needs to be done, well, more than something – a dozen things. The challenge is how to remain balanced throughout the day and how to effectively do what needs to be done next, while actually enjoying the day.
Start at the beginning – the beginning of your day, that is. The day of a therapist does not start in the office; it starts at home, from the moment you wake up. You get ready for work, looking professional and prepared, but you probably have to make breakfast for the family, care for a pet, pack some lunches, throw a batch of laundry in the washer, and get the kids off to school. It sometimes feels as though you did a half day’s work before you even left the house.
Take a moment and reflect on your morning this morning, from the time you awoke to when you entered your office door. How many things happened, what was the pace like, and how did you feel most of the time?
Then it gets worse. Once in the office, you scramble to prepare for the clinical day: typically collecting files on each patient for the day, checking for voice and text messages, returning deadline-sensitive calls, opening yesterday’s mail, responding to administrative or colleagues’ requests, rearranging your schedule to accommodate cancellations and new appointments, putting water bottles out in your office or turning on the office coffee maker. You have, in mere moments, fully activated your hyperactive monkey or foraging squirrel brain, which frenetically, relentlessly jumps from one task to another.
We know that it proves best to arrive at your office at least 15 minutes before your first scheduled client. Stop for a moment and reflect: Did you achieve that goal today? How often do you achieve that adequate pacing?
All that frequently occurs before your first patient, when your professional duty is to listen attentively, behave optimistically, and relate energetically. All that proves well-nigh impossible when we do not practice self-care.
Take a mindful moment before you start the day. Even a two-minute pause helps (Geller, 2017). A brief centering exercise may suffice: sitting quietly in the office for 30 seconds, breathing calmly and deeply, clearing your mind of things that need to done later, and focusing on the here and now – and then on the patient you are about to see. These pauses, these moments of reflection, are practicing mindfulness.
Try to do likewise before each patient session throughout the day. We anticipate (and sometimes join) your objection: “And exactly where do I get this imaginary time between sessions?!” Your time between sessions is short and already packed. You rush around for 10 minutes, scribbling or dictating a session note, visiting the bathroom, gulping some water, answering an assistant’s or colleague’s urgent question. We get it: You only have a few minutes.
Yet, you need to center yourself and prepare for the next session, too. Give yourself two minutes to orient yourself toward the next client. Read over your brief note from the last session. Recall the key event or interpersonal interaction the client discussed – and the dominant emotion related to it. Then calm yourself. Focus on your breathing, try to recall what you were feeling with the patient at the end of the last session. Take a pause that refreshes. Walk out to greet your patient with contentment and conviction.
This brief, pre-session mindfulness will likely result, according to clinical experience and research studies (e.g., Dunn et al., 2013a, 2013b; Ryan et al., 2012), in you relating better to clients and sensing their emotional states more quickly. You will be pleased, for both your clients and yourself, at achieving this attunement and ensuing improved effectiveness.
Some clinicians also perform a mindfulness or presence preparation at the end of the day, as the last thing they do before walking out of the office (Geller, 2017). Ensure your bodily needs are met, clear your mind of distracting elements, and consciously form an intention for presence. Intentionally put aside all of the lingering thoughts about the day’s sessions and the feelings they left you holding. A centering and clearing of your mind – and a transition to your next encounter, often with your family or friends.
Mindfulness has three key aspects: (1) a purposeful choice to direct or concentrate attention on the moment-to-moment presence; (2) observation of one’s moment-by-moment internal and external experience; and (3) an unjudging acceptance of and curiosity about whatever might be felt or observed. The desired consequences are decreased strain or stress, improved awareness of positive experiences, increased connection to others, and enhanced appreciation of our own (and others’) sense of humanity (Shapiro & Carlson, 2009). When realized, these goals simultaneously promote clinician self-care and client growth.
For these reasons, many healthcare professionals have pursued formal training in mindfulness. The most common paths appear to be meditation classes (covered in the next section) and Mindfulness-Based Stress Reduction (MBSR), a systematic eight-week training program involving structured teaching of meditative behaviors and their integration into one’s daily routine (Kabat-Zinn, 1990). MBSR often offers a one-day retreat near the end of the program to deepen one’s practice and to solidify one’s skills. Originally designed for individuals facing stress disorders, the program has been widely adapted to specific populations, including practicing psychotherapists and therapists in training.
Accumulating research confirms the multiple self-care benefits of mindfulness for mental health professionals but, unfortunately, no improved treatment outcomes for their patients. An early meta-analysis of 20 studies on mindfulness-based training found that mental health professionals benefit personally from the training, with no negative results reported (Escuriex & Labbe, 2011). Studies have found that clinicians report gains in emotion regulation, decreases in stress and rumination, and improvements in empathy, presence, and self-compassion (e.g., Dunn et al., 2013b; Jain et al., 2007; Sedlmeier et al., 2012; Swift et al., 2017; Zainal et al., 2013).
At the same time, no conclusive evidence yet exists that those practitioners trained in formal mindfulness have better treatment outcomes than those who are not (Swift et al., 2017). The patients of mindful therapists usually report more effective working alliances and more session satisfaction, but not significant differences in overall psychotherapy success. Hence, we can confidently conclude that mindfulness training provides effective self-care for psychotherapists (which suffices for our purposes!), but does not necessarily lead to better patient care.
Core skills of MBSR training involve a mind-body scan exercise, focus on the breath, and physical movement while maintaining mindful concentration. Below we review and harvest those core skills in the interest of your self-care, both at the office and away from the office.
The mind-body scan is similar to progressive muscle relaxation. Both are body-based and body-focused. In addition, both start with a focus on the extremities and move inward toward the core of the body.
However, they entail different processes. With progressive relaxation, one is tightening and relaxing muscles and muscle groups. With a mind-body scan, one is sensing, observing, and feeling the body – intentionally, without direct purpose, in an unjudging manner. What is there? How is it? What is the sense or experience? The mind-body scan can be done lying or in a sitting position. Often calm instrumental music or nature sounds play in the background.
Physical movement frequently co-occurs with mindful concentration. The MBSR protocol includes walking meditation, hatha yoga, and various stretches. Those can be incorporated into work hours with a little creativity and commitment.
Several clinical colleagues engage in mental mindfulness while attending to their physical posture in the office chair. They hold their body upright yet relaxed: centered, straight, calm, and positive. They activate a physiological sense of equanimity through aligning their minds and bodies together.
When directed by the MBSR leader to focus their attention on particular feelings or sensations, participants redirect this attention when their mind wanders. If strong feelings arise, you simply observe the feelings in a nonjudgmental manner. “Just watch and observe, not control.” Intentionally focusing on subtle pleasant and warm sensations may bring into awareness positive qualities and kind impulses that you wish to embody. Or, to quote Jackson Browne, mindfulness strives to bring into being a “peaceful, easy feeling” of being in and with the world.
Before therapy sessions and during difficult sessions, regain your centered presence. Simply observe the process outside of you. Take a few deep breaths, and if you are so trained and inclined, teach patients to do likewise. Let the stress fade, let your viscera return to homeostasis. Focus on your positive qualities and the kind impulses that you wish to manifest toward your patient (and yourself). In a word, reclaim your mindfulness.
Most mindfulness experts encourage daily, self-directed 30- to 45-minutes of practice. That might certainly prove possible away from the office, but unless you have a patient cancellation or substitute mindfulness practice for your lunch hour, not as feasible at the clinical office.
The events preceding mindfulness can influence the likelihood that it will persist. One strategy involves priming recent activities, such as reflecting on internal self-processes or a positive relationship. For instance, researchers (Rowe et al., 2016) have used a 10-minute writing exercise as a prime before a meditation session. Those using a self-compassion prime (“Visualize and write about being totally compassionate and warm toward yourself”) or a secure attachment prime (“Visualize and write about a person with whom you have/had a close secure relationship”) demonstrated higher willingness to engage in further mindfulness training (relative to a control condition). Hence, mindfully introduce positive cues and expressive primes to promote mindfulness over the long run.
At the risk of sounding too technical and neuroscience-y, we would also note that regular mindfulness practice results in valuable neurobiological changes. A systematic review of the research (Chiesa & Serretti, 2010) suggests that mindful meditation causes increased activation of the prefrontal cortex and the anterior cingulate cortex; those changes may facilitate the reduced emotional reactivity to negative emotions and physical pain observed in clinical outcomes. Likewise, a review of neuroimaging studies on functional and structural brain changes (Hatchard et al., 2017) found that MBSR training positively effects areas of the brain related to attention, introspection, and emotional processing. Increased present-moment awareness may occur via increased activation of the insular cortex and reduced emotional reactivity through decreased activation of the amygdala.
A growing number of helping professionals report daily practice of mindfulness themselves. Therapists who practice mindfulness exercises are far more likely to recommend the practice to their patients. Even if one does not adopt regular practice away from the office, one can easily use mind-body scans, nonjudgmental observing, physical movement, and mindful primers throughout the day at the office as a refreshing reset activity.
Our frenzied monkey brains frequently require something physical and concrete to anchor meditative practice, especially when we are beginning to learn the skills. The process of breathing constitutes the most prevalent anchor. This makes a lot of sense: It occurs naturally, it is ubiquitous, it repeats in rhythm, it is body-centered, it is personal, and it is, after all, you. But, usually, you are not consciously aware of breath.
An initial starting point is to shift one’s focus to breathing and the body (as it is doing the breathing). Focus and experience how you breathe. Just attend, just experience. Do not judge it, or analyze patterns, or control it. Just breathe and attend to the breathing process. Experience it.
After a few moments, observe whether you mostly use your nose or your mouth. Observe which is used during the inhale and the exhale. Same or different? Breathe using your nose for both the inhale and the exhale. Breathe using your mouth for both the inhale and the exhale. Observe how each feels. Observe the similarities, observe the differences. Just breathe. Experience it.
Over time, discover your easiest and most comfortable breathing process, which will prove most calming for you. It is likely to have a slow pace and a natural rhythm. It is likely to consist of a two- or three-second inhale via your nose, a brief hold, followed by a four- or five-second exhale through your mouth. As you use breathing as a meditative anchor, you will probably breathe six or seven times per minute. Over time, you will probably come to breathe more deeply so that both your inhale and your exhale will get longer.
Meditation is intentional observing without judgment. Observe whether you are breathing equally through each nostril. Or, are you using one nostril a bit more than the other? Observe whether the favored nostril is the same one as the one you noticed previously. It probably is not, as we use alternative nostrils over the course of the day and night, in a cycle that ranges from a half-hour to three hours. This is the nasal cycle. Had you ever noticed it before?
Try breathing primarily through your left nostril for several breaths. Try breathing through your right nostril for several breathes. Observe the similarities, observe the differences. Just breathe. Experience it.
Try a cleansing breath: a short, strong, and quick exhalation through the mouth, starting from the lowest part of the lungs with a forceful contraction of the belly. Then inhale in a slow natural passive manner via your nose. Do it several times. The cleansing breath offers both release and energy, a vital combination for real-time self-care.
Another technique to try is breathing with long exhalations. That down-regulates the sympathetic nervous system and vagal pathways of defense (Geller, 2017). Our lungs long for deep breaths instead of the shallow gulps of low-oxygen air found in most offices, classrooms, and auditoriums. One of us (JCN) practices long exhalations before teaching classes and presenting workshops.
Experiment with other anchors beyond breath. Sound – whether instrumental music, wind chimes, rain from a sound generator – serves the anchoring purpose. Being in nature may prove better for you. Just listen. Concentrate your attention on the sounds. Let the central sound slowly shift. Observe the sound, observe your sense of the sound.
One of our master therapists sits outside her office building twice a day, rain or shine, to absorb the scents and nonjudgmentally attend to the natural sounds. She occasionally adds physical movement or body stretches, but continuously observes her breath and surroundings without judgment. She feels particularly refreshed from these mindfulness breaks when others most complain about the weather conditions: The psychotherapist especially enjoys the scent and sound of heavy rain and muffled snow.
An object typically anchors a “seeing” meditation. Attend deeply to a fallen leaf, or a flower, or the branches of a tree against the background of a blue sky. Focus and concentrate. Contemplate. Just observe and experience. There are many ways to intentionally concentrate and nonjudgmentally observe. Try different ones, and see which emerges as the most interesting and effective for you.
Meditation is a maddeningly simple process: simple because it just involves letting go, but maddening because our foraging squirrel minds have not been schooled to set aside the need for task accomplishment and goal achievement. Meditative escapes bring relief by rejecting ordinary thoughts and adopting a serene observational stance. The various meditative techniques disrupt the mind’s tendency to jabber on, analyze ad infinitum, and “solve.” Letting ordinary thoughts come and go without judgment or interference requires hours upon hours of practice.
By abandoning egotism and adopting a pervasive attitude of modesty, practitioners can avoid the burden of holding an overgrown self to inflated standards (Baumeister, 1992). The broader philosophical-cognitive shift that life is suffering – the first of Buddha’s Four Noble Truths – can help us abort the extended “pity parties” we throw for ourselves. Meditation clears the mind, refreshes the spirit, and centers us through close connection with the physical world.
One of our master clinicians described his meditative practice this way:
About six months ago, I realized that my ambitions and driven behavior were taking a toll on me – physically, emotionally, and spiritually. I knew that I had to find some way to slow myself down. I wanted to find something that I could do just for myself – not for my family, not for my clients, and not for my vitae. So I began meditating. Each day I make time to meditate. Periods of sitting motionless and intensely focusing my mind, calm my thinking, lift my mood, and soothe my soul.
As psychotherapists, we are taught to detect and examine what is not working in order to figure a way to produce changes and corrections. We do the same thing with ourselves – as therapists and as humans. A session with a patient ends with an awkward, incomplete feeling. We puzzle over it, asking ourselves what we missed and if we expressed something incorrectly. We do so in a self-critical manner, and our self-talk often takes on a harsh tone, concluding with “Aghhh! I should have said that. What a dumb-ass thing I said!” (That’s a verbatim thought of one of the course’s authors, by the way.)
Mental health professionals are a competitive lot, with extensive training in critical thinking. That ability teaches us not to accept facts and descriptions at face value, but to dig deeper and ask skeptical questions. Those critical thinking skills are all too frequently turned against ourselves, 24 hours a day. We must learn to turn off our skeptical, competitive skills at times.
One of the most impactful questions we pose to our uber-self-critical supervisees is: Would you encourage your client to critique and condemn him or herself the way you are doing now? Most therapists manifest far greater compassion for their clients’ struggles than for themselves in an admittedly “impossible profession.”
Self-compassion proves essential when reflecting on our clinical mistakes, empathic failures, and painful life experiences. Training and practice in self-compassion prove helpful in mitigating our uber-critical thoughts and in developing inner resources to successfully engage difficulties in daily life.
Self-compassion consists of three interrelated elements: kindness, a sense of common humanity, and mindfulness (Neff, 2003, 2011). The Mindful Self-Compassion program (Neff & Germer, 2013) employs a variety of meditations (loving kindness, affectionate breathing) and informal daily practices (soothing touch, self-compassion self-talk). Here’s how these core activities can be used for self-care at, and away from, the office.
Try a self-compassion break, an experiential exercise that centers on a recent stressful event that evoked a negative emotion in you. Consciously think of that event in a three-part manner: “This is a moment of suffering” (mindfulness); “Suffering is part of life” (common humanity); and “May I be kind to myself” (self-kindness). This exercise typically stops rumination, decreases isolation, and begins a comforting process.
Several of our workshop participants routinely practice a loving-kindness meditation, involving the mental repetition of a generous statement as the focus of attention. Something along the lines of “May I be kind to myself,” “May I be safe,” or “May I be loved.” These can be performed while sitting, while walking, or while performing a physical task, such as washing your hands. To maintain this meditation in their self-care repertoire, most colleagues conduct it at the same time each day (e.g., beginning of the work day, leaving the office for the day) or during the same tasks (e.g., before checking e-mail, before eating lunch).
Another exercise of the Mindful Self-Compassion program involves developing one’s personal compassion voice. This expands the self-talk phrase used in the loving-kindness meditation into a natural conversation with the compassionate part of one’s self. The compassionate self is motivated by the intention “I love you, and I don’t want you to suffer.” Each therapist finds the words most comforting for her: “You can do it;” “Good try, very creative;” or “I love you” are three examples.
Self-compassion requires a candid exploration of the core values that bring meaning and satisfaction to your life. Self-kindness and self-responsiveness requires deep knowledge of what we really care about in life. Reflecting on these values, we naturally begin a self-reflective process of whether we are living the life that we value.
Not unique to self-compassion, but invaluable nonetheless, are bodily awareness of emotion and the means for managing difficult emotions. Emotions have both an emotional (or bodily) component and a thought component. Most of us get lost in the thought component, defending our action and finding fault with others. Slowing down and finding where in the body one feels emotion helpfully changes the perspective from which we approach difficult emotion.
This process is similar to Gendlin’s (1978, 2007) focusing technique. Therapists and clients are taught to locate and anchor the feeling in their bodies. When they do, the emotion starts to change. Participants can then soften that area, allow the sensation to exist, and then soothe themselves.
A final exercise, and corresponding skill of self-compassion, addresses our human negativity bias. For evolutionary reasons, we scan for threats to our physical and emotional integrity. Once a survival skill, this kind of scan is much less relevant in a relatively safe environment, and now it generates a negative worldview and a negative initial filter through which we experience events. Psychotherapists need to create and maintain a positive orientation (or bias). By intentionally savoring good things in our lives and good qualities in ourselves, we can disengage from our innate negativity and enjoy our lives more fully.
In the office, self-compassion soothes our inner critical voice, reorients us toward positivity, builds empathy for patients, and facilitates healing for all involved. Outside of the office, it remains an essential skill for a happy and healthy life. Engaging in some of these self-compassion activities will probably feel a bit forced and overly simplistic when you first attempt them. We assure you that this initial response changes over time with continued practice, as you determine which exercises fit you best.
Meditative and mindfulness practices emerged at least 3,000 years before the establishment of contemporary positive psychology, but they share the quest to understand and foster flourishing (Seligman & Csikszentmihalyi, 2000). Positive emotions are markers of flourishing.
Our emotional or affect system constitutes a signal system that alerts us to what is happening, both around us and inside us. When a threat presents, we experience physical sensations that signal “danger,” which triggers the classic fight-or-flight response. When no threat is present, and we are engaged in pleasurable activities, the affective signals are of pleasure, joy, pride, and love. Positive emotions are more subtle than negative emotions, because of the latter’s importance for basic survival. Thus, most people (including psychotherapists) are more attuned to negative affect and less aware of their positive emotions.
Decades of research have shown that the overall balance of positive to negative emotions predicts an individual’s subjective well-being (Diener, 2009). Positive emotions, such as joy, contentment, and love, also produce flourishing and widen our perception of sensation and depth of thought. Meditative practices are designed not only to reduce stress, but also to focus and expand awareness of positive emotions. Positive psychology, in particular, has developed a multitude of interventions for triggering positive emotions and building them into a self-care routine. Gratitude exercises are among the best-documented and -researched successes.
One gratitude exercise has become a classic: three good things in life. To do the exercise, one generates a list of three good things about one’s life experienced recently. The intervention can involve writing a brief daily note about three positive things about the last day, making a daily entry of good things in a gratitude diary, or identifying those things as one falls asleep. The results are modest but meaningful decreases in negative affect and increases in well-being (Sin & Lyubomirsky, 2009).
Therapists can turn their daily schedule book into a gratitude diary by using one of the unused spaces on each sheet to jot down “good things” as they occur during the day. Examples abound: a prideful feeling about identifying a missing link in a patient description of a problem situation, a joyful feeling about a patient’s recovery or triumph, an optimistic feeling from an unexpected call from your partner telling you of something positive, a satisfied feeling of finally getting a billing problem resolved with an insurance carrier. Moments of happiness and other positive emotions occur every day, but we often fail to absorb and internalize them. We also fail to record them to remind ourselves of them later. Making note, both in mind and in writing, helps the positive emotions and gratitude stick.
Another gratitude-enhancing exercise is the gratitude letter. We can readily incorporate this into the daily routine at work or at home, as it need not take a lot of time (and thereby become another burden). Many therapists incorporate it into their regular phone contacts or e-mails (“I am grateful for the patient referrals you have sent me and for having you as a professional resource”). Others do so on Facebook, as they keep up with their friends. For example, when they see that a friend is visiting a city they once visited together or engaging in activities they did together, they add a brief comment like: “A wonderful town. I remember the great visit we had there a few years back. Hope you get to go to that tiny restaurant on Main Street that we found so amazing. Enjoy your trip, and thanks for sharing. I appreciate having you as a friend.”
A gratitude visit obviously requires more effort. One can physically travel to the other person (the preferred method) or arrange for a video conference (via FaceTime or Skype). Such visits might be conducted once a month rather than daily, but produce the same benefits as the other gratitude interventions (Sin & Lyubomirsky, 2009).
Consider making gratitude telephone calls, rather than a visit, once a month. Thirty minutes is a nice amount of time to catch up with another person and express your gratitude for their support and caring.
One colleague extensively involved in professional associations knows someone in almost every medium-sized or large city in the United States. When traveling on business, he looks ahead to whom he knows in the destination city and reflects on whom he would like to thank. He e-mails that person and invites him or her to dinner when he is in town. He enjoys the planning process itself – considering the people he knows in a given locale, reflecting on their interactions, considering the nature of their relationship, and determining whom he owes the most thanks. The reminiscing itself yields gifts, which bring positive affect into the present. The later actual gratitude visit is like an added bonus!
The life of a psychotherapist remains a rewarding one. The vast majority of therapists report that their positive work experiences far outnumber the negative. They are thankful for their career and would pursue the same career choice if starting over again. Mental health professionals have much to be grateful for, and your self-care calls for you to express that gratitude and trigger its flourishing emotions.
Part and parcel of mindfulness is awareness of transition moments. These refer to acknowledgment of changing activities and people (Geller, 2017). There are many more events in our daily life than we think about, and many more transitions, large and small. During our therapy day, for instance, each patient is another transition. Tending to our bodily needs over the course of the day involves transitions. Completing a telephone call and moving on to answering some e-mail involves a transition. We often do not think about our daily experiences in and of themselves.
Slow down such transition moments by noticing and letting go of what came before. Mindfully put space between events, and arrive at the new moment or activity – with intention. This increases your presence in each new activity or interpersonal encounter. Pre-session mindfulness, outlined earlier in this course, and transitions between work and home, prove cases in point.
The customs of our community, country, religion, and culture also provide elements of mindfulness. Customs surrounding meals, births, deaths, birthdays, and marriages are shared meaning-making events, offering models for sharing, expressing, and grieving. All cultures have specific shared rituals that facilitate a sense of gathering, community, and belonging.
All psychotherapists share at least one ritual: the ceremonies when they received their graduate degree or certificate that authorizes them to practice. Each of us may have had several of these; for example, graduating from school, passing a licensure exam, achieving certification by a credentialing body. These are joyful and proud moments, marking our passage into a community of recognized professionals. It is a mindful moment.
Likewise, termination with a patient after a successful course of psychotherapy represents a special transition and ritual for helping professionals. A sense of achievement, completion, connection, and yes, loss pervades those final sessions. Despite having collectively terminated with thousands of patients, we (the authors) never tire of that mindful encounter.
Mindful meditation embraces these rituals as well. Beholding comes to mind. After five or 10 minutes of mindful meditation, you can focus on a favorite “terminated patient,” next on a current “good patient” (one you enjoy working with), and then a “difficult patient” (who argues, criticizes, and demeans). Finally, focus on the shared humanity with that difficult individual, embracing his or her fear and vulnerabilities, bringing compassion for him or her in the same way you want to be treated and loved yourself.
This process enriches your self-care in that it structures the drawing upon and drawing out of shared humanity. It helps you feel humble and empathic for your patient. “There for the grace of God go I” or similar thoughts from religious or spiritual traditions may occur to you. The process may also raise your awareness of countertransference reactions of which you were previously unaware, or new insight into the possible dynamics and coping mechanisms of your patient. All this is accomplished mindfully, without judgment on the inevitable human limitations of your patient or yourself.
The life of a psychotherapist is filled with close encounters with, and bodily responses to, intense emotions, human suffering, and occasionally the most joyful of experiences. It is hard to maintain one’s own emotional balance in the face of the chaos and agony of an active practice. Mindfulness tools, broadly defined, enable you to maintain (or regain) that crucial sense of calmness and perspective. In this respect, mindfulness constitutes an essential professional and personal skill.
Our professional training ensures a modicum of mindfulness – focused attention, watchful observing, and thoughtful reflection – but that base can be further developed at any point. Mindful exercises and activities, hailing from far more than meditation, can be learned and practiced. We have acquired and practiced such skills alone at times and with colleagues at other times; chase your preferences for what feels most natural and effective.
We opened this section of the CE program with a quotation from the Buddha: “It is better to conquer yourself than to win a thousand battles.” We will (almost) close this section of the course with a favorite tale attributed to the Buddha that illuminates the essence of the mindful way. One day the Buddha was walking along a road when a man jumped out from behind hedges and lofted a glass orb toward him. He saw it coming in advance, had time to catch or deflect it, but instead let the glass object hit him on the chest, fall to the ground, and break. The man cried out, “Buddha, why did you not catch it?” The Buddha serenely replied, “Just because you throw it does not mean I have to catch it.”
When patients, administrators, and life throw obstacles your way, you do not have to catch them. Take that mindful pause, breathe deeply, detach yourself nonjudgmentally, just watch and observe. Cultivate self-compassion for your immersion in an “impossible profession” and express gratitude when possible.
Mindfulness is a skill, a tool, and a resource, but also an enduring way of approaching the world, your patients, and yourself. It represents a humble and modest appraisal of one’s place in the cosmos – seeing and sensing our common humanity with others. Mindfulness produces compassion for others, and compassion for yourself. It involves a grateful appreciation of the challenges and opportunities before you.
Take the moment now to pause, breathe slowly and deeply several times, and be still both physically and mentally. Sense and appreciate your being right now.
The human body is the best picture of the human soul.
– Ludwig Wittgenstein
Psychotherapists are so intent and focused on sophisticated self-care methods that we frequently overlook the biobehavioral basics of self-care: adequate sleep, rest, nutrition, exercise, and human contact. Do you subsist during the practice day, as did one of us (JCN) for years, on diet soda and pretzels between appointments? How many hours of sleep do you need – versus what you typically get? Do you sit all day, major muscles stiffening, while your facial muscles work overtime expressing emotions? Let’s not neglect the fundamentals of self-care.
As authors, we half apologize for reminding a sophisticated audience of these basic needs. Yet the biology is elemental and demanding. The body in psychotherapy has become marginalized; many therapists have historically practiced from the head up. But the bodily cure fits comfortably with the talking cure.
We need to take our bodily reactions more seriously, as the body constitutes the fountainhead of human experience. It is, in Wittgenstein’s words, “the best picture of the human soul.” And, as Freud repeatedly reminded us, being a psychotherapist does not make us any less human.
We mind the body of the psychotherapist by addressing sleep, bodily rest, nutrition, exercise, and human contact (including sexual gratification). These, quite literally, embody our energy and engagement.
In our interviews with master practitioners, a recurrent self-care theme is obtaining ample sleep – a powerful solution to occupational distress. Said one: “I have really made an effort, though not always a successful one, to get eight hours of sleep a night. It makes a huge difference.” Said another: “I privilege my sleep above social entertainment and passive leisure. If I don’t get enough sleep, my energy and health are for shit.”
Our watchword as psychotherapists should be “Mens sana in corpore sano” (a healthy mind in a healthy body). It’s extremely shortsighted to see sleep as an obstacle to productivity. A nightly investment in sufficient rest leads to greater resilience and accomplishment.
The research literature attests to the value of maintaining a standard sleep window to secure sufficient sleep. Some call this sleep hygiene and others label it sleep stimulus control, but whatever name is used, many meta-analyses support its efficacy for obtaining sleep and treating insomnia (Irwin et al., 2006; Morin et al., 1999; Smith et al., 2002). Those same meta-analyses further demonstrate that sleep stimulus control typically results in a shorter sleep latency (the amount of time needed to fall asleep) and in fewer negative side effects and addictive consequences than sleep medications.
Stimulus control instruction is one approach to improved self-care by harnessing the power of both the person and the environment. Consider adopting the following sleep rules or instructions (Bootzin, 2005): Lie down intending to go to sleep only when you are sleepy. (This rule strengthens the bed and bedroom as behavioral cues for sleep.) Do not use the bed for anything except sleep; do not read, watch television, or eat in bed. (This rule weakens the association of the bed with activities that might interfere with sleep.) If you find yourself unable to fall asleep, get up and go into another room. (This rule dissociates the bed from the frustration and arousal of not being able to sleep.) Stay up as long as you wish and then return to the bedroom to sleep. Get out of bed if you do not fall asleep within 10-15 minutes. (The goal is to associate the bed with falling asleep quickly.) Do this as often as necessary throughout the night. Set your alarm and get up at the same time every morning irrespective of how much sleep you got during the night. (This rule helps the body to acquire a consistent sleep rhythm). Get up at the planned time in the morning. If you are suffering from sleep disturbance, do not nap during the day. You may be sleepy for a few days, but you will develop a rhythm of sleeping and a strong association that “a bed is for sleeping.”
Stimulus control instructions work for most people, but not for everyone. As we always recommend, try it and see if it works for you.
Another approach takes the position that sleep is less critical than relaxation. It recommends going to bed at a specific time each day (maybe 10:00 p.m.) and getting up at a specific time each day (maybe 6:30 a.m.). Do not worry if you do not sleep, just rest in bed with your eyes closed. If you are still awake after 10-20 minutes, get in a comfortable position and rest. Do not worry about sleeping. Do not roll around in bed. Do not get up for warm milk or go to the bathroom. Many people having trouble sleeping become more active, which prevents them from sleeping – and also exhausts them. Do not worry if many thoughts are running through your head; thinking consumes less energy than tossing and turning in bed (or getting up multiple times). Your mind will eventually calm itself. You will eventually fall asleep. Eight hours of relaxation is about as refreshing as five hours of sound sleep. You will not be at the top of your game the next day, but you should function adequately.
One of us (JCN) has been impressed in his own life with the results of rising with the sun and sleeping with the stars, 5:30 a.m. to 9:00 p.m. It is a highly natural – in tune with nature – sleep pattern. The other (GVB) goes to bed around 11:00 p.m. and gets up at 7:30 a.m. Both schedules get us to the office early for concentrated stress-free work. Both patterns also ensure the 8.4 hours of sleep the average adult requires (typical range of 7-9 hours).
A question guaranteed to provoke animated discussion in our self-care workshops is, “How many of you get sufficient sleep each night?” Only about two-thirds of the psychotherapists’ hands go up in the affirmative.
Let’s start comprehensive self-care by tending to your sleep, thereby recharging your battery. A body in motion deserves predictable rest.
The lyrics of Jackson Browne’s song “Running on Empty” warn us that running on empty, without rest or restoration, means pushing harder and enduring more pressure. Running on empty frequently means “running blind” and “running behind.”
Psychotherapy consists of two or more physical presences in the consulting room. Interviews with experienced psychotherapists reveal that they suffer physically in a number of ways from practicing the craft (Shaw, 2004). When we are empathic, we respond physically to patients, such as an anorexic or bulimic patient talking about vomiting and diarrhea. We vicariously feel anxiety as patients describe a panic attack or physical abuse. The body is a receiver.
The stress associated with conducting psychotherapy is often manifested in muscle tension, particularly in the jaw, neck, and back. As a result, many of us find massage to be an effective and pleasurable method of treating muscle discomfort. Facial massages are natural antidotes to experiencing and expressing strong emotions through the major face muscles. Massage not only helps muscles relax but also clears away waste products and the assorted pain that comes with tight muscles. Physiologically, it stimulates blood flow, improves muscle tone, and enhances the immune function (Field, 1998). Psychologically, a course of massage therapy reduces anxiety and depression almost as much as psychotherapy, according to a meta-analysis of dozens of studies (Hou et al., 2010; Moyer et al., 2004).
Make no mistake about it: The amount of sitting time is associated with increased health risks. A meta-analysis of nine studies (involving 448,285 participants) demonstrated that sitting time significantly increased the probability of cardiovascular disease and diabetes (Bailey et al., 2019). Physical activity attenuates but does not remove the increased risk.
Our muscles stiffen when we sit for such long hours. In the office, we have learned to take short walks between sessions, even if only within the office or to the bathroom, and to give ourselves facial massages to ease tension in the jaw. Outside the office, we have learned to schedule full-body hour-long massages.
Massage offers a recuperative rest from the turbulence of stress (Cady & Jones, 1997; Field, 1998). As stated by one master therapist: “I go to a professional massage therapist once a month or more. It helps keep me in touch with my body. It also reverses the roles; I am in the position of receiving rather than giving the care.” Another master clinician used massage in a creative and specific manner:
“I was doing marital therapy with a couple, and they were really struggling with some issues that were difficult for me to be emotionally present to. What I did during the course of seeing them in therapy was set up a weekly session of massage for myself. I experimented with having my massage session before seeing the couple versus after seeing the couple. Although it felt good afterward, it seemed to be more helpful ahead of time. It helped me be centered and balanced and emotionally present in terms of what they were experiencing and my being moderator and counselor.”
Different massage techniques are readily available from professionals in virtually all localities: deep muscle, Swedish, hot stone, acupressure, Rolfing, and more. Taking a class or receiving individual treatments can be most useful, both for immediate stress reduction and for ongoing body self-care. We urge you to try it if you haven’t already. It is simply invaluable.
During sessions in the office, try to keep your body straight and sit erect. Some therapists appear to flop around or remain off-kilter. The therapist’s physical posture is a crucial indicator. Sitting with a good posture throughout the session helps you give clients your full attention and preserves your energy. Be balanced and flexible, always gravitating to your center (Rosenbaum, 1999). These quick, restorative practices can be implemented often in and between sessions throughout the workday (Bush, 2015).
Move your body often to counteract the sedentary nature of your workday. Go for brief walks between appointments or during lunch. Learn to massage your own feet between sessions. Make sure you stretch your shoulders, neck, and legs now and then. Avoid a motionless sitting position that reduces your circulation and energy. In sum, give your body a rest between the relentlessly emotional but sedentary sessions.
In this regard, we have been surprised by the large number of workshop participants reporting that fellow mental health professionals routinely come to work even when they are physically ill. Several colleagues have implemented office guidelines and center policies that require staff arriving sick (as evidenced by coughing, fever, congestion, lethargy) to be sent home – “Not in a punitive manner but in support of their own well-being. So far, pretty good compliance except for our assistant director!” Bodily rest proves even more urgent when actively ill.
In one of our first workshops on self-care, we quizzed the participants privately and anonymously about their nutrition during the workday. Only one-quarter of psychotherapists thought their nutritional intake was healthy and adequate; three-quarters thought it was unhealthy, inadequate, or both. Since that inauspicious discovery, we always take a few moments to address nutrition and hydration.
Up until the past 15 years, our own performance in this domain of biobehavioral self-care was dismal. We subsisted throughout the day on coffee, sodas, and quick finger foods, only to become ravished and eat one humungous, unhealthy meal at 8:00 p.m. We have become more mindful of our nutrition of late – perhaps because we are heeding our own advice, perhaps because we are in middle age, or perhaps because our caring spouses are determined to improve us (our money is on the last factor).
One of our psychotherapy patients was a registered dietician who helpfully suggested that we monitor our fluid intake during the workday. After thanking her for the recommendation and commenting on her reenactment of devoting more time to others than to herself (her presenting problem for treatment!), we gratefully did so. We were consuming about 70% of the recommended daily intake of 3.7 liters (125 ounces) for men (2.7 liters or 91 ounces for women (The National Academies, 2004). That’s total water consumption each day, derived from both beverages (about 80% of the total) and foods (about 20%).
More specifically, base your water intake on your body weight. Aim for drinking half your body weight in ounces daily; for example, if you weigh 150 pounds, your daily target would be about 75 ounces. Losing just 2% of your body’s water will result in your feeling tired and weak. You might want to monitor your own hydration for a few clinical days.
Several of our adventuresome trainees have tested themselves “in the spirit of science.” Drink less than you are drinking now, strikingly less – like one glass every four hours – and notice how your thinking changes, slows, gets fuzzy. Try this on the weekend, not on days you are seeing patients.
More than one healthcare colleague has argued that it seems unprofessional to drink water or coffee while seeing clients. We respectfully disagree. Practitioners, indeed, all humans, need to regularly consume water and maintain hydration.
The self-care imperative is to eat balanced nutritious meals and to hydrate adequately during the day. The standard North American diet, featuring large proportions of refined foods and sugary drinks, rarely meets the target. Mood follows food, and mood swings follow blood-sugar swings (Korn, 2014). As part of their self-care, many mental health professionals alter their diets and adopt healthier choices. For example, one intern “practiced veganism in an effort to clean up my act, quite a change from my burger-downing days.” Improved energy, weight, and concentration ensued.
Following a self-care workshop, a participant wrote: “I’ve begun by addressing some basic things and have made a commitment to myself to do something not spectacular but something no matter how small that builds on my daily self-care. Today it was getting breakfast, listening to relaxing music, and massaging my feet. And so it begins.” Exactly so.
Surveys involving thousands of psychotherapists discover that 71%-89% engage in regular physical exercise (Barrow et al., 1987; Knapp & Sternlieb, 2016; Mahoney, 1997; Sherman & Thelen, 1998). Jogging, walking, workouts, tennis, racquetball, swimming, and bicycling lead the list of favored activities (Barrow et al., 1987). Here are 10 verbatim testimonials from our master clinicians and workshop participants:
A final illustration comes from Jeffrey Kottler (1986, pp. 138-139) in his book On Being a Therapist. Here is his personal testimony on the salubrious effects of exercise:
When I ride my bike the wind washes me clean. Everything I have soaked in during the previous days oozes out through my pores, all the complaints and pain and pressure. I feel only the pain in my legs and lungs as I climb up a hill pumping furiously. And then I coast down as fast as I can, never knowing what is around the next turn. For an hour or two I am no longer a receptacle for other people to dump their suffering. Nobody catches me on my bike. There is no chance to think or I will miss a pothole in the road. And it takes too much concentration watching for traffic, pacing my rhythm, switching gears, working on technique, saving my strength, breathing slow to consider anything outside my body. After a ride through the country, I feel ready again to face my clients, my past, and my uncertain future.
Associations between exercise and well-being have been documented repeatedly for decades. Such exercise most positively impacts the therapist’s physical stamina, emotional mood, and mental stamina. The affective beneficence of exercise in psychotherapists converges, of course, with the empirical research attesting to the link between exercise and decreases in depression, anxiety, and body-hatred (Hays, 1995; Stathopoulou et al., 2006). Dozens of meta-analyses (Pope, 2017) conducted on hundreds of treatment outcome studies demonstrate significant positive outcomes supporting the efficacy of exercise. We suspect exercise may be even a more powerful benefit for psychotherapists – whose jobs are typically highly verbal, sedentary, and nonphysical – than for people generally.
As the world knows, sedentary time (like psychotherapists sitting for hours upon hours) is detrimentally linked to obesity, diabetes, cardiovascular disease, and premature mortality. The good news: Meta-analyses demonstrate that activity-permissive workstations, such as standing desks and meaningful movement, can effectively reduce occupational sedentary time, without compromising work performance (Neuhaus et al., 2014). Thus, taking vital breaks, standing during parts of sessions or office work, and moving between patients decreases the health risks of our sedentary occupation. Our feet want to break out of offices to move around and feel the earth.
A cautionary word about exercise for the idealistic, perfectionistic practitioner (that’s 94.3% of us): Please keep your exercise expectations realistic. Heed the sage words of one of our master practitioners:
“While my exercise is modest (20-25 minutes of Nordic Track or stationary bike with sit-ups) every other day, I am realistic that I will be more likely to succeed at this level rather than if I set myself impossible goals. Since I am always encouraging my clients to assess both their confidence and their competence when they set goals, I am trying to take my own advice.”
Psychologist Harry Harlow (1958) was among the first, and inarguably the most memorable, to experimentally demonstrate the inborn need for human contact that clinicians have witnessed for centuries. You may recall that Harlow took infant monkeys away from their biological mothers and gave them instead to two artificial, surrogate mothers, one made of wire and one made of cloth. The wire mother was outfitted with a bottle to feed the baby monkey. But the babies rarely stayed with the wire mother longer than it took to get the necessary food. Babies strongly preferred cuddling with the softer cloth mother, especially when they were frightened, even though it/she did not offer milk.
Such contact comfort is of overwhelming importance in the development of affectional response. Certainly we cannot live by milk alone. We all need contact comfort, a little cuddling.
Some clinicians keep a favorite pillow or afghan nearby during sessions, to hold or touch. Others allow for time for phone calls to close friends and family members in the midst of a busy day. One master clinician schedules a weekly lunch with his spouse and small children, providing an opportunity for physical affection and meaningful contact between psychotherapy clients.
Of course, the need for contact comfort can be partially satisfied in sexual relationships. Saul Bellow’s Herzog (1964, p. 166) goes so far as to argue that “the erotic must be admitted to its rightful place, at last, in an emancipated society which understands the relation of sexual repression to sickness, war, property, money, totalitarianism. Why, to get laid is actually socially constructive and useful, an act of citizenship.” We would not go that far, but Herzog vividly makes the case for sexual gratification.
Psychotherapists, being more human than otherwise, are subject to the same biological needs and amenable to the same physical releases as other humans. In this course, we remind you to reconnect to the body, that thing below your neck, in your self-care.
All healthcare practitioners assuredly know the preceding material and routinely encourage their patients to mind their bodies. But if there is a first-place, blue-ribbon award for the disconnect between psychotherapists’ practices with patients and those same psychotherapists’ practices with themselves, then it is certainly in the realm of satisfying one’s biological needs.
We trust that this course has neither belabored the obvious nor insulted your intelligence. Sleep, bodily rest, nutrition, exercise, and human contact are indispensable for well-functioning, career-sustaining psychotherapists. Get real, get basic, get bodily self-care.
I don’t want to be a product of my environment. I want my environment to be a product of me.
– William Monahan
Most recommendations to promote psychotherapist self-care and to prevent burnout fall into the category of changing the person (Maslach & Goldberg, 1998). This is essential and comprises much of the content of this course; however, it is incomplete. An exclusive focus on changing the person is too individualistic; it may erroneously blame the clinician, and it ignores the organizational and managerial factors that may cause the problem in the first place (Leiter & Maslach, 2005).
In our research on self-care methods (e.g., Brady et al., 1995), psychotherapists rate “making organizational changes at the practice” their least frequently used method. It came in dead last among 27 self-care activities. Psychotherapists are far more comfortable and skilled in changing behavior than in changing the environment.
It is as though we are committing in self-care the same fundamental attribution error we occasionally commit in our professional practice. In arriving at causal attributions, we tend to overestimate patient’s dispositions and to underestimate the power of their situations. In other words, we are prone to weigh internal determinants too heavily and external determinants too lightly. We are thus likely to explain patients’ behavior as resulting predominantly from their personality, while we often minimize (or even ignore) the influence of the particular environments in which they find themselves.
This erroneous cognitive-emotional pattern results in blaming the therapist solely for burnout. In truth, it is both a personal problem and a job problem. Mental health professionals tend to look only for personal solutions to burnout when we should be looking at both environmental and personal fixes; that is, to fix the persona and the underlying system (Leiter & Maslach, 2005).
Let’s correct the fundamental attribution error: Harness the subtle but pervasive power of the environment to replenish yourself. Make the environment work for you, not against you.
We need to comprehensively address the person of the psychotherapist, the work environment, and their interaction. The workplace, the systems, the physical environment, the administration, and the sociocultural context – all are involved in the genesis and maintenance of self-care and the lack thereof. This is particularly true for mental health professionals working for clinics, agencies, hospitals, and other settings outside of private practices. Dysfunctional organizational factors contribute mightily to therapist distress and discourage responsible self-care.
In this section of the course, we traverse the infrequently used but powerfully effective strategy of environmental control. Humans, unlike the nonhuman species on the planet, have enormous capacity to remake their environment. In the words of B. F. Skinner (1983, p.127), “One can picture a good life by analyzing one’s feelings, but one can only achieve it by arranging environmental contingencies.” Make your working environment work in the cause of your self-care. Make your environment a product of you!
Again, the number of specific techniques for implementing the strategy is endless. For some, a flourishing environment might be aesthetics in your office decor; for others, replenishment in your refrigerator, nourishment from an administrator, or simply a humane caseload. This section of the CE program is designed to assist you in refining or creating a flourishing environment.
Let’s begin with the tangible: the physical environment in which you work. What does it feel and look like? Attractive, soothing, and professional? Or, as is tragically the case in many public sectors, bland, irritating, and institutional?
Research has identified several features of psychotherapy offices that support treatment objectives (Augustin & Morelli, 2017). Perceived quality of care and comfort improve with an increase in office softness, personalization, and orderliness (Devlin et al., 2013). Some practitioners believe that mounds of paperwork connote a busy and successful practice; however, most patients perceive such an office as disorderly and haphazard. The color red is frequently experienced as a sign of danger or failure, as in a teacher’s red ink marks. Softer, lighter, and warmer colors tend to enhance the environment.
Humans also prefer natural-color wood with a grain, as opposed to non-grain surfaces. But there is a limit to how much wood should be visible. Science demonstrates that when natural wood surfaces exceed about half a room’s surface, they lose their stress-busting effects. Some wood, but not too much, is the moral for client comfort (Augustin & Morelli, 2017).
Like it or not, research also supports displaying your credentials in the office. Yes, it appears self-serving and pompous to some of us to do so, but clients desire to see your expertise. People rate therapists with five or so posted credentials most favorably (Devlin et al., 2009). So, promote your expertise without overdoing it or leaving patients feeling inconsequential.
Take Freud’s workspace, for example. Although Freud was commonly regarded as a workaholic, his patients found that he possessed a special gift for creating a happy balance in everything he undertook, including the appearance of his home at Berggasse 19 (in Vienna). The Wolf-Man, one of Freud’s more (in)famous analysands (in Gardiner, 1971, p. 137), writes:
“I can remember, as though I saw them today, his two adjoining studies, with the door open between them and with their windows opening on a little courtyard. There was always a feeling of sacred peace and quiet here. The rooms themselves must have been a surprise to any patient, for they in no way reminded one of a doctor’s office but rather of an archeologist’s study. Here were all kinds of statuettes and other unusual objects, which even the layman recognized as archeological finds from ancient Egypt … A few potted plants added life to the rooms, and the warm carpet and curtains gave them a homelike note. Everything here contributed to one’s feeling of leaving the haste of modern life behind, of being sheltered away from one’s daily cares.”
You don’t need to be a Freudian to learn from Freud: Create a welcoming office environment for patients and a flourishing environment for yourself. One of our colleagues purchases a bunch of fresh flowers each week for his office. One of the clinics with which we consult purchases inexpensive posters for the hallways and rotates patient-created paintings for the waiting rooms. Physical improvements need not be expensive, just expansive.
Take an environmental audit of your workspace. Consider the comfort and appeal of:
As part of furniture, please, please invest in high-quality office chairs. Large enough to accommodate clients of all sizes; sturdy enough to support their spines; moveable enough to give them a sense of control. Check that your own chair comfortably supports your work day after day, year after year.
Several of our colleagues have found value (and joy) in revamping their offices following our self-care workshops. One wrote that “My team has worked on making the environment more pleasing to work in by removing clutter and updating the decor.” Another enthused, “My office looks great now! I have decorated it with pictures, a lamp, and a candle to give a warmer feeling to a cold environment.”
Independent of the physical surroundings, we can cultivate our sensory awareness. Sensory diversion can help temporarily mollify nearly all forms of painful affect and replenish our overtaxed senses. Behold your surroundings using vision, hearing, touch, gustation, and olfaction. People pay good money to stay at beautiful vacation resorts, to hear mellifluous music, to acquire luxurious fabrics, to eat gourmet food, and to wear pleasant scents. Build these into your work environment.
Whenever possible, let the sun shine through. Natural light boosts comfort and mood, be it by windows, skylights, or mirrors. If your office lacks windows, employ table lamps and floor lighting with soft bulbs, for that warm and cozy vibe. Overhead fluorescent lighting is the least preferred, but ubiquitous in most office buildings.
Heed the extensive research on the optimal sorts of artwork to use in healthcare environments to lower stress and promote contemplation (Augustin & Morelli, 2017): landscapes and gardens; low hills and mountains; lush green scenes; calm water scenes; healthy fresh flowers; caring relationships among people; and paintings or posters with positive cultural associations. You know your tastes and caseload, but abstract art can prove upsetting and confusing to many clients.
As we try to increase our sensory awareness, look to children – the sensory masters. Children focus outward, not inward. On our way to adulthood and genuineness, we have diminished the capacity to appreciate our surroundings. At times, our introspective nature can cause us to become so serious that we are oblivious to everything around us. Maybe we cannot fully recover the pristine senses of childhood, but we can teach ourselves to appreciate what used to come naturally: to observe and luxuriate in our environment.
Cultivate your office’s indoor climate – a combination of temperature, humidity, air movement, and air quality (Augustin & Morelli, 2017). Human mood and mental performance generally peak in spaces that are approximately 70 degrees Fahrenheit with air quality and movement. Lack of control over air presents a growing concern for physical and mental health; indeed, one of us moved a private practice office largely because of our inability to regulate and improve the air. Provide your clients with alternatives to individualize the indoor climate by offering blankets, opening windows, and regulating the heat or air conditioning. All part of healing by environmental design.
Small additions to the workspace can produce large benefits. Positive distractions, such as a fish tank or a pastoral landscape, provide a brief respite from the weighty matters of psychological treatment (DeAngelis, 2017). Bring a bit of nature into the workspace with plants or landscapes. A lit candle, pleasant artwork, and soothing music in the waiting room go a long way in conveying comfort and privacy.
A concrete (and inexpensive) method is to establish a refreshment center for ourselves in the office. This center consists of mouthwash, cologne/perfume, brush, comb, washcloth, and so on, to physically refresh us between appointments. If you have more than a drawer or file cabinet to spare, then also add water and fresh snacks to sustain you during the day. Several of our colleagues fondly call this the “Me Center” – something clandestine just for them.
In auditing the physical environment of your work, highlight the safety of the practice environment. Evidence is accumulating about the personal safety of psychotherapists. In one of our nationwide surveys of psychotherapists, for example, 60% were often or sometimes concerned about unwanted calls to the office, 36% about unwanted calls to home, and 28% about verbal threats to personal safety (Guy et al., 1992). In a review of the research base (Pope & Vasquez, 2016), more than 80% of psychotherapists feared that a client would physically attack them and about 20% had actually been attacked by a client. The greatest risk for attacks occurs on inpatient psychiatric units and for forensic specialists.
Work-related stalking of mental health practitioners also seems to be on the rise (Storey, 2016). Somewhere between 6% and 15% of us will be stalked sometime during our career (Carr et al., 2014; Kivisto et al., 2015). It can be perpetrated by clients, acquaintances of clients, and, less often, coworkers. We cannot do our best work if we fear for our personal safety.
What can therapists do to prevent violence against themselves? Among the most frequent recommendations are:
Should a realistic threat of violence arise, therapists routinely notify security personnel or law enforcement and then obtain a restraining order. Ethical codes allow for termination of services in such instances. Your self-care demands a comfortable and safe practice environment.
Psychotherapists don’t enter the field because they are fascinated with its business matters. We desire to be healers, not managers; helpers, not accountants.
One way to help therapists differentiate themselves from their practices is to ask them to imagine the practice as a distinct entity, something apart from themselves – another person, so to speak (Grodzki, 2003). Get distance and perspective on it.
When we look at our practice in a dispassionate and distant manner, we frequently conclude that we are devoting inordinate time to dreaded, nonclinical responsibilities – the paperwork, the scheduling, the billing, the cleaning. In these instances, we recommend three paths or combinations thereof. First, hire office assistance for scheduling, billing, notes, taxes, authorizations, phone calls, the Internet, and other business aspects that you dislike or find nonproductive. Second, learn to streamline your office practices. Perform appointment scheduling as part of the session. Write uncomplicated notes. Minimize billing by insisting on payment each session or each month. Train staff members or the answering service to reduce interruptions and to do more of your paperwork. Third, if you are confused about the right path for you, hire a business coach or consult your accountant for cost-effective approaches to take. The goal is to maximize your time in what you enjoy and do well and to minimize your time at what you deplore and others can do as well if not better than you can.
Let me cite my own (JCN) personal history: Years ago, I learned that I was happier absorbing extra overhead expenses for my part-time practice in order to maintain a large, comfortable office and have an office manager handle all of the financial and billing matters. Yes, I net less private practice income as a result, but I enjoy my clinical work and therapy environment much more.
Some self-care pundits urge practitioners to eliminate managed care entirely from their practices. It certainly reduces the business hassles of independent practice. We remain stridently ambivalent about this proposition. Personally, we do not participate in any managed care: One of us never accepted managed care, and the other purged it from his practice after six months. However, we are part-time practitioners with established practices who can afford to be selective. Such does not prove feasible for most younger, full-time, and institutional practitioners. One-size-fits-all advice usually fits no one particularly well.
In all of these decisions, base your business decisions on love, not fear (Grodzki, 2003). Fear-based practice is loathsome, grim work, whereas love-based practice is grounded in love of the work and pride in your vocation. “Mindful practice” in action! In fact, a therapist’s sense of “feeling blessed” is most highly correlated with experiencing therapeutic work as healing involvement (Orlinsky & Ronnestad, 2005).
The late Robert Sollod, a cherished colleague, was fond of exhorting colleagues to build “behavioral boundaries.” He based this counsel on his studies of the shamanic traditions of separating healing from the rest of life through rituals. Shamans would perform an entry ritual in preparation for the healing – incense to purify, a ceremonial dance, spending a little time aside – and then later a closure ritual – cleansing, moving out of the space, being alone for a period of time.
Building behavioral boundaries entails temporarily separating yourself from the clinical world by means of routine and time. The routine between patients, or between your last patient and your personal time, might consist of going to the bathroom, washing hands, taking a nap, listening to music, or a lengthy commute. Give yourself time between patients. Ten or 15 minutes to make notes on the previous session, review notes on the forthcoming session, return a call, stretch, breathe. It might lengthen your day and diminish your income, but as Irv Yalom (2002, p. 167) argues, “It is worth it.” Extra time between patients may be poor time management, but it is definitely good stress management.
Define your behavioral environment broadly: people, places, and things. The boundary may be a few minutes of personal time between patients or it may prove to be a few minutes away from colleagues. A master therapist in our studies discovered that his “open door policy” between patients in his center was backfiring; he was inundated with colleagues, office staff, and non-urgent matters that robbed him of his energy. “I found that I needed to keep the door closed to really attend to my clients and to myself.”
Insofar as you control your work environment, arrange it in your interest. Take control of your schedule. Keep your caseload at a manageable level. Limit your practice to a specified number of high-risk and high-demand patients. Schedule lunch, power breaks, and the gym. Consider flextime and paperwork days from home. Book time off for training and continuing education. Take all of your vacation days, not like the typical American who leaves five to seven days unused each year (Schwartz, 2013).
Schedule the final patient of your day carefully. For one straight year, every Wednesday my (JCN) last patient in the evening was a woman who had lost her young child, her only child, to an automobile accident. She was suffering from unearthly grief and PTSD. Her pain left the office with me. Finally – remember, we do not profess to be experts in practicing self-care – we discovered that it was inadvisable to schedule her last in the day.
At this point in our workshops, participants are howling in their seats. “Hey, we don’t have that kind of control at our clinic! We are assigned patients, and they are scheduled for us. What about us?” (Over the years, we have learned to anticipate these protests and state in advance that we will address these particular demands in a few moments.)
Practicing psychotherapy in institutional settings – clinics, hospitals, HMOs, centers, and various institutes – presents a host of encumbrances not afflicting independent practitioners. There are, simply put, fewer degrees of freedom.
In fact, the phenomenon of psychotherapist burnout was initially coined by Herb Freudenberger (1975) out of his work in an institutional setting. After a few years of unrealistic expectations, draining work schedules, mountains of paperwork, financial cutbacks, and working with severe mental illnesses, enthusiastic idealism slowly morphs into cynical detachment. The bright lightbulb has burned out.
In the worst of clinical institutions, practitioners are confronted with unresponsive management, lack of control, scant staff, insufficient rewards, inadequate funding, unrealistic demands for high productivity accompanied with little autonomy or flexibility, and ultimately a breakdown in the therapeutic community. No wonder that career dissatisfaction is highest and burnout most common among practitioners working in institutional settings.
At the same time, the bulk of research indicates that it is neither the institutional setting itself nor the high demands alone that lead to psychotherapist stress. Highly demanding jobs can be made less stressful without lowering the number of demands – so long as the level of constraints can be reduced and supports can be expanded. These results are consistent with the demands-supports-constraints model of occupational stress (Kramen-Kahn & Hansen, 1998; Rupert et al., 2015). That is, clinical positions in institutional settings will continue to be demanding, but increasing the support and reducing the constraints make the positions rewarding and manageable.
Numerous studies and even a meta-analysis (Lee et al., 2011) have demonstrated the strong relation between a clinician’s sense of control and all dimensions of burnout (Rupert et al., 2015). Those in more control of their workloads and schedules experience less burnout and more work-life satisfaction. Got that? The number and severity of patients contribute to some extent, of course, but the operative factor is control. Control over activities, work schedule, client selection, treatment decisions, vacation time, paperwork – all of it.
Increasing practitioner support, both inside and outside of the office, has been covered thoroughly in this CE program, such as in nurturing relationships. Support can take the form of clinical supervision, consultation, clinical teams, peer support, cuddle groups, and the like. In one study, the authors (Farber & Heifetz, 1982, p. 298) pointedly conclude that “most therapists found the role of support systems essential. All those who could, utilized supervisory relationships to help them through difficult moments; of those who were not being supervised, 51.1% relied on informal support of colleagues.”
Reducing constraints, or more positively, enhancing practitioner control is thorny in institutional settings, unless you possess the power, of course. The elements of enhanced control/lowered constraints include responsive management, greater practitioner autonomy, creative work patterns, honest communication, and respect for the person of the clinician. Leaders must recognize that clinicians can be traumatized and that vicarious suffering is part of the work. Managers must strive to enhance the work experience to give workers more influence in policy decisions.
In attempting to increase supports and lower constraints, beware what has been labeled “false interventions” (Edelwich & Brodsky, 1980) that are handed out like candy on Halloween. When the staff becomes disgruntled and the workplace stale, managers are apt to run a one-day workshop. Spirits are lifted for a few days or weeks, but little has materially changed. What all false interventions share in common is the premise that a person can deal with burnout once and for all through a single expedient. All of them attempt to disguise the omnipresent reality of occupational hazards with short-term fixes that, in actuality, fix nothing of the underlying causes in the long term (Edelwich & Brodsky, 1980). Treat the systemic roots, not only the acute symptoms.
Increasing supports and control allow practitioners to work in high-demand institutional settings with severely and chronically ill patients. The research confirms the collective experience: It’s not the patients who drive us crazy, it’s this place and its crazy administration.
The grim truth about behavioral health practice is that organizations create much of the exhaustion and demoralization behind burnout. Thoughtful reviews by Maslach and Leiter (1997; Leiter & Maslach, 2005) conclude that the prevalence of burnout is exploding because of the social environments in which people work. Specifically, in many institutional settings:
Altruistic, idealistic psychotherapists mismatch with the contemporary demands of most institutions, whether they be public nonprofit or private for-profit organizations. It’s not the direct services that does most of us in; it’s the agency politics, the dehumanizing conditions, the hellish bureaucracy, the insensitive administrators, and the asinine guidelines about how to treat your clients. What makes us tick, what inspires us to work well is devalued. Indeed, blaming “compassion fatigue” or “burnout” on an individual allows agencies (and professions) to escape their systemic responsibilities. The gap between the prime motives of the helping professions and the core demands of institutional employment proves too much for many of us.
The good news, so to speak, is that any of the foregoing six mismatches provides direction for reversing burnout, or as we would prefer to phrase it, promoting self-care. Reverse the six causes, and you immediately see the need for institutional settings to provide a sustainable workload, feelings of choice and control, recognition and reward, a sense of community, fairness and respect, and valued work. Both the person and the environment, both the practitioner and the organization, need to commit to redressing the misfit.
Traditional organizational development tries to identify deficit gaps, such as those problems outlined above; in addition, we recommend looking for abundance gaps in behavioral health organizations. How can the organization make itself more responsive, more equitable, and more rewarding? Perhaps this approach sounds idealistic, but increasingly centers for positive organizations, such as one at the University of Michigan, identify organizational dynamics that lead to strength, renewal, and resilience (Christensen & Shen-Miller, 2016). That’s consistent with our emphasis throughout Leaving It at the Office and the research evidence that proactive self-care usually outperforms reactive treatment of burnout.
A courageous examination of your workplace’s physical environment, social support, and administrative values may lead to a decision that it cannot be fixed, nor even measurably improved. The work environment is not tenable, perhaps even toxic, for you. If you can’t improve it, then you may need to replace it; you may need to leave that workplace.
Following are three representative observations from workshop participants who came to such somber conclusions:
“The self-care seminar helped me to realize that working in this particular university counseling center is a toxic work environment, at least currently, and is not likely to change in the near future. As a result, I will be going into full-time private practice after this semester ends. Probably not the response that you will get from many directors, but one that is right for me.”
“Your workshop helped me accept that there is really no way for me to remain in full-time practice at this time without compromising my emotional, mental, interpersonal, and spiritual well-being. So I have scaled back my practice (about 30% so far) and am seriously considering closing it – at least temporarily.”
“I realized that I had to make a decision as to what kind of work environment I needed. After the workshop, I got myself settled, pursued different options, and left the agency. I adored my clients but the place was not worth my happiness and health. Thanks for the prompt and the feedback.”
Each colleague took brave actions in the best sense of self-care. Each colleague, at last contact, was eagerly pursuing alternatives – in a different employment setting or in different work spheres – gardening, painting, and dance – “that float my heart.”
Although we had been doing yoga twice a week in the office, this has fizzled and I need to revive it. I must admit that I worry how this is perceived by the administration … slackers in the counseling center. Should I care? This is a classic conflict in a productivity-minded work environment. My challenge now is how to best intervene in a systemic way in a university culture where workaholism and devaluing self-care are relatively entrenched. I’d appreciate hearing any words of wisdom about how to create a systemic change in self-care.
Uh-oh. Words of wisdom? Hmmm. Well, certainly we feel supportive of our workshop participant’s attempts to build self-care into the institutional ethos. And we are absolutely empathic. It frequently feels that we are only self-care-spitting into a workaholic ocean. Workaholism is rewarded lavishly in most employment contexts, as we can guiltily attest. It is challenging enough to implement self-care in ourselves, but a Gordian knot to implement it into an entire institution.
On one level, self-care runs against the ingrained notion that “we are here for the clients, that patients must come first.” Understandably and rightly so. But the apparent paradox resolves itself as soon as one appreciates that psychotherapist self-care is a critical prerequisite for patient care.
Organizations frequently devalue supportive work practices, which are seen as self-indulgent in environments stressing productivity and efficiency. Further, individual practitioners are stigmatized as vulnerable if they accept support. Several surveys and a couple of interview studies have determined that mental health professionals may be vulnerable to poor levels of self-care because they perceive the expression of needing support as psychologically threatening. A psychotherapist is supposed to be “the strong one,” right? (Canter, 1997). The psychotherapist’s own fears of being a client (feeling out of control and, compared to colleagues, perhaps not coping well with high job stress) and the perceived cost of the support process itself disincline individuals to create supportive environments (Walsh & Cormack, 1994).
What, then, can be done? Build a self-care village in a workaholic world.
First, pour the foundation by persistently advocating for self-care as a means of increasing productivity, enhancing outcomes, and promoting employee satisfaction and retention. As long as occupational stress is perceived as boosting productivity, there will be no compelling reason for organizations to even consider reducing or eliminating worksite stressors (Maslach & Goldberg, 1998). Self-care improves both practitioner health and patient outcomes – they are inseparable in our “business.” Argue long and hard, at every opportunity in your institution, for psychotherapist self-care as improving the bottom line.
Next, erect the village’s buildings by challenging the pernicious beliefs that psychotherapists who seek support are weak and will be subtly punished (Walsh & Cormack, 1994). Daily we remind our clients that seeking psychological treatment is healthy and mature, but many in our profession do not apply the same lesson to themselves. Praise publicly your colleagues who privilege their self-care and set reasonable limits. Cultivate an ethos of staff support.
One interesting method is Me-Time (Maier & Van Rybroek, 1995). During this scheduled period during the workday, distressed clinicians are encouraged to vent negative feelings that could potentially affect their work with patients. The combined forces of venting, group support, and peer feedback help relieve the distress and develop effective coping strategies (Miller, 1998).
Finally, top off the buildings’ roofs by modeling self-care yourself and structuring it into the operation. Put self-care on the agenda of each staff meeting. Track it as you would patient outcomes. Post your self-care goals near your desk. Organize in-service activities or retreats on clinician well-being. Include it in the annual staff evaluations. A creative colleague in one of our workshops wrote that “I brought back some of the ideas from those presentations and shared them with my staff. We held a retreat in January and focused on the issue of self-care. As a result, we have been drawing names each week and honoring a different staff member (kind of like giving them an extra birthday). This seems to have helped the morale.”
Self-care needs to be addressed at multiple levels: the individual practitioner, the physical environment, the organizational context, and the larger systems of the mental health professions. Only a multifaceted systems approach will suffice (Coffey et al., 2017). Before we conclude this section of the course, we devote a couple of pages to these larger, systemic contexts.
We need to improve the psychological healthiness of our training programs. In one study of graduate students in psychology, 83% said their training program did not offer written materials on self-care and 63% stated that self-care activities were not provided (Munsey, 2006). Based on our teaching experience and the training literature, a horde of urgent corrections spring to mind, including:
Most practitioners are unprepared by graduate programs for the emotional demands of full-time clinical work. A conspiracy of silence surrounds practitioner distress and impairment. This omission encourages psychotherapists to distance themselves from their troubled colleagues and to think of them as a separate “not-like-me” group (O’Connor, 2001). This demonizing must stop, beginning with graduate training.
State licensing boards operate primarily to protect the public – a necessary and noble function – but some boards do not see a way to help practitioners in the process (O’Connor, 2001). Diversion and rehabilitation programs are effective in most cases, but some boards seem bent upon retribution. It’s time to enlarge the mandate of licensing boards to protect the public by educating and rehabilitating practitioners.
Society is best served by strengthening a large cadre of well-trained, effective professionals available to serve the underserved. Individual practitioners, concerned laypersons, and professional associations can advocate for legislation that enlarges the mandate of licensing boards to assist, not just restrict, practitioners.
Self-care starts at the top: the large professional organizations. Dozens of these associations in psychology, psychiatry, counseling, social work, mental health nursing, family therapy, and so on can propel the self-care movement. Here are a few prime examples of how leadership from the top might proceed:
Environmental control – making the environment work for you, not against you – correlates highly with self-care effectiveness. It is ironic that psychotherapists who are typically adept at maintaining interpersonal boundaries frequently ignore the environmental practicalities that profoundly drive their career satisfaction. Avoid the fundamental attribution error by harnessing the power of the environment to enhance your practice and yourself. The goal is not to survive but to flourish.
Self-care consists not simply of the internal or psychological factors of the psychotherapist, nor simply the external or situational factors. Instead, it is truly an interactional environment-person match in which the particulars of individual practitioners intertwine with the specifics of the work environment. The greater the gap, or misfit, between the job and the person, the greater the likelihood of stress (Maslach & Goldberg, 1998). The greater the congruence, or fit, between job and person, the greater the rewards and satisfaction.
Being more human than otherwise, we psychotherapists possess the capability to remake our work environments. In the words of this section’s epigraph, make your environment a flourishing product of you.
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