Reading H

1. Learn what can contribute to burnout.
2. Understand specific stress coping techniques.
3. Comprehend the five fundamental lessons of self-care.

Most professionals begin their careers with little or no information about what they will really experience as practitioners or academics in a particular field. Building on childhood and adolescent ambitions, they careen from their years in undergraduate programs directly into their graduate training with little time for thought or preparation. The graduate years consist of anxiety-ridden rituals of hard work and dedication. There is practically no time to reflect on the wisdom of the commitment to join a particular profession, since all of the student's energy is taken up with the tasks of gaining entry in the first place. It is only years later, after graduating, passing the licensure examinations, and engaging in the first job or two in the field, that the average individual begins to recognize the tremendous effects that the decade of hard work has had on his or her life. (Kilburg, Nathan, & Thoreson, 1989, pp. 15-16)

The above quote points out the tendency of the mental health professional to neglect self-examination of which self-care is a component – throughout the professional development journey until there comes a point when he/she begins to consider the existential professional questions of "What is it all about?" and "What price am I willing to pay for this profession?" In the formal education and training of mental health professionals who will work in high-stress situations, self-care is rarely discussed (Christopher, 2006). We are typically trained to over-look our needs as mental health professionals and to focus on the care of others (O'Halloran & Linton, 2000). That is why this chapter is included in this book. It is important for those of us in the mental health professions (students and experienced professionals alike) to reflect throughout our professional development on our self-care and commit ourselves to this practice throughout our careers. Every mental health professional is vulnerable to the possibility of impairment (Norcross & Barnett, 2008). A commitment to self-care can simply help us be the best mental health professionals we can be and can prevent possible impairment in our therapeutic work. We need to practice self-care from the beginning of our work (Bein, 2008). It can help us listen to the difficult stories our clients tell. Self-care can promote resilience that can prevent the fatigue described as "empathy fatigue"— when the mental health professional's wounds are stirred by the life stories of clients (Stebnicki, 2007). Self-care can also help us with our psychological, spiritual, and emotional vulnerabilities, so we can be the best wounded healers we can be, bridging the world of wellness and the world of illness. Practicing self-care can strengthen our vulnerability so we can: (a) effectively draw on the suffering we experience in the world (Bein, 2008), and (b) make choices, provide empathy, and experience stamina in therapy that benefits the welfare of the client (Mander, 2009). If we do not develop coping strategies, we may leave the mental health profession, act dysfunctionally at work—perhaps by not setting appropriate boundaries —or practice while impaired. We must renew ourselves and nurture our happiness (Willer, 2009). For example, leisure impacts the work and personal lives of mental health professionals by encouraging balance and integration, improving coping abilities and work performance, and creating meaningful connections (Grafanaki et al., 2005).

This chapter on self-care will attempt to avoid "should-ing" the reader with pat formulas of self-care and instead will encourage the mental health professional to practice self-care in a humane, self-respecting, realistic manner. It is anchored in the belief that all of us deserve compassion, including ourselves (Neff, 2008). It means that we attempt to find the precarious balance between being aware of the storyline of our lives and not becoming lost in it. That means we have reactions in response to what happens to us (we are not in denial about them), but we do not become lost in those reactions, lost in the storyline. Self-care assists us in experiencing this balance, because through self-care we are compassionately attending to ourselves. This chapter begins with a philosophical discussion of self-care followed by discussions of the basic hazards of crisis intervention work (burnout and related issues), which underscore the importance of self-care, self-care approaches, the application of a self-care philosophy, and approaches to a case example.

Most ethical codes of the mental health professions have sections on professional self-care, but because we come into these professions to learn to help others, this very focus makes self-care a complicated process of practicing self-care while we are caring for others (Norcross & Barnett, 2008). Because the therapeutic relationship is core to the therapeutic process, and the mental health professional invites the quality of the therapeutic relationship, self-care of the mental health professional has an important influence on therapy (Norcross & Barnett, 2008). Therefore, mental health professionals have both an ethical and moral responsibility to be committed to self-care.

Those of us who work in the mental health field as professionals know the importance of self-care. How can we avoid viewing self-care from an idealized ethical imperative and instead use that ethical imperative as more of a guide? This is where our philosophical view of self-care is critical. We can read about self-care and become frustrated or discouraged because of the "messiness" of being human. We may want to practice better self-care, but life may have given us personal or professional stressors over which we have no control and that, in effect, limit our self-care practices in terms of time, energy, or money.

We need to first look at what or who in our lives gives us a sense of hope and helps us face the day. What provides us with hope and meaning in our lives? The positive impact of being connected with these resources can have a positive contagion effect on our clients. By nurturing ourselves, we can nurture our clients (Hood & Ersever, 2009). Exercises are provided at the end of this chapter to help the reader clarify these resources. However, it 67 is the underpinnings of the self-care perspective that are so critical in our approaches to self-care. If we take information on self-care and apply it to ourselves in an idealistic, rigid, formula-based manner, we can end up with a high degree of negative self-criticism. Paradoxically, we have increased the very stress we are trying to reduce. We can also practice self-care so "perfectly" that it essentially backfires: we are stressed out from how much we attempt to care for ourselves.

The resolution to such binds and paradoxes concerning self-care is to hold two opposing truths as both being true: We do need to practice self-care in order to be the best mental health professionals we can be; and we need to acknowledge up front that this is an ideal that we cannot achieve, because we are human beings working with human beings in an imperfect world. As hard as we try, we will make mistakes and not be able to reach the ideal. We need to avoid catastrophizing our failures and our inability to reach ideal self-care standards. The reality is that we have difficulties and stressors beyond our control, as do our clients, and we work in an imperfect world that does not always provide enough or the right resources for ourselves or for our clients.

We step outside the paradox by holding the ethical imperative—the ideal of self-care—as a guide, while being flexible in the application of the ideal to our lives. While we need to follow the maxim "Do no harm," we also need to keep in mind some others, such as the presented Self-Care Tips.

We need to practice "self-care on the run," meaning we need to personalize and individualize our self-care practice with consideration of the realistic limits facing us in terms of time, energy, and money. We need to be flexible and adaptable to fit our changing needs and the changing contexts of our lives. We need to make a commitment to practice self-care through the integration of our self-care activities into our daily lives, by listening to our stress levels and responding to them. We need to address our whole being (mind, body, emotions, and spirit) through practices such as meditation, self-talk, and physical exercise.

A part of this approach is the inclusion, then, of self-forgiveness for when we do not reach our ideals of self-care. Smedes (1984) provides a self-forgiveness model with four stages:

1. Hurt: We hurt ourselves through our mistakes and vices.
2. Hate: We hate ourselves for having done wrong.
3. Heat: We write our own script; we allow others to love us.
4. Home: Our split within ourselves is healed.

The practice of self-forgiveness applies to those self-care practices that we deeply wish we did better. For example, it may be very important to us to lose weight, but as hard as we try, we continue to struggle with a sensible weight-loss plan. This is where the axioms listed above and a self-forgiveness model are so important. They can help us develop a realistic self-care plan in the context of our present situation and avoid the harsh self-criticism that can so easily evolve from not being able to meet our ideals. Connected with the concept of self-forgiveness is self-compassion. Self-compassion means that we are kind to ourselves and show understanding for ourselves when we experience failure, inadequacy, and misfortune; we respond to our human suffering in a balanced way (Neff, 2008). To respond in a balanced way, we need to practice self-care as we are aware of our pain. It is from this philosophical view of self-care that some of the hazards of crisis intervention work are explored. The hazards presented here are: burnout, secondary traumatic stress disorder, vicarious traumatization, and compassion fatigue.

• Progress, not perfection. One can work at achieving progress and not be discouraged or overwhelmed by flaws or limitations, even though perfection cannot be reached.
• Don't compare your insides with other people's outsides.We tend to compare how we feel with how others look and thus may underestimate their struggles in life, which actually might be similar to ours.
• Run interference with yourself. We may need to do the opposite behavior of our tendency in order to act our way into a new way of thinking or feeling.
• Be responsible for the effort, not the outcome. We are only responsible for making the best effort we can make, but we must recognize that we cannot control the outcome of our efforts.

Originally the term burnout came from the psychiatric view of patients being "burned out" from a holistic perspective where they were completely exhausted (Paine, 1982, p. 16), and then the term began to be applied to work situations where health care volunteers showed signs of having more problems than their clients (Freudenberger, 1974, 1975). Freudenberger's writings were based on experiences at a New York City drug abuse community agency. While drug abusers were labeled "burnouts" (i.e., they only cared about drugs and slowly had become unmotivated and incompetent), Freudenberger used the term "burnout" to describe the workers in his 1974 article, "Staff Burnout." While that article seemed to kick off a collective, intuitive understanding of the term, we still seem to have difficulty defining it with clarity (Skovholt, 2001). There are numerous definitions of burnout as described by symptoms (negativism, exhaustion, cynicism, etc.; Leviton, 1993) or dimensions ("lack of personal accomplishment, emotional exhaustion, and depersonalization and deindividuation of clients"; Maslach & Jackson, 1986, as described in Kanel, 2007, p. 32).

The definition of burnout used in this text is:

In addition to the term burnout, other terms have emerged to describe what happens to crisis intervention workers that can lead to burnout. These terms include secondary traumatic stress disorder (STSD) (James, 2008). STSD has also been called vicarious traumatization (VT) (McCann & Pearlman, 1990), compassion fatigue (Daniell & Dingman, 2005; Figley, 1995), and negative countertransference (Greene, Kane, Christ, Lynch, & Corrigan, 2006). Specifically, vicarious traumatization is what happens when the mental health professional adopts the trauma-related symptoms of the client (Halpern & Tramontin, 2007; Hoff, Hallisey, & Hoff, 2009; James, 2008). Compassion fatigue is ongoing severe compassion stress in which one feels helpless, confused, and isolated; it is similar to posttraumatic stress disorder (PTSD), but different in that the reaction is not to the event, as in PTSD, but to the person telling about the event.

Although the different terms can be confusing, at their essence, these inter-changeable terms describe an out-of-balance relationship between the mental health professional and the client; they provide mental health professionals with a framework to understand some of the dangers of crisis work. When the mental health professional intervenes in a crisis, there may be a temptation toward heroic action that minimizes one's own needs. Personal needs, physical health, nutrition, safety, and self-direction may fall by the wayside for the mental health professional as he/she is drawn into responding to the crisis (Leviton, 1993). Such "other direction" can lead to burnout, in which the mental health professional is negative, cynical, and less supportive toward clients (Vettor & Kosinski, 2000).

The danger of burnout and STSD is that they can endanger the welfare of both the client and the mental health professional. This danger, then, underscores the importance of the self-care of the mental health professional. Workers in crisis situations need to know how to identify this state so they can respond to it effectively (Kanel, 2007). Approaches to self-care can assist in the prevention or intervention of burnout and STSD. The more coping strategies possessed by the mental health professional, the less burnout experienced. Coping strategies that are inadequate increase stress and burnout, while constructive ones decrease them (Wilkerson, 2009).

The above description of a strategic retreat is an example of how self-care can be used in a self-respecting, compassionate manner. Sometimes life simply gives us too much, and we need to simply do the best we can to catch our breath, to regroup.

General Techniques

There are numerous techniques available for self-care. Some of these are outlined in the additional readings section at the end of this chapter. A few are highlighted here.

A Substance Abuse and Mental Health Services Administration (SAMHSA) (2005a) brochure provides ten tips for effective stress management:

1. Familiarize yourself with signs of stress.
2. Get enough rest, exercise regularly, and maintain a healthy diet.
3. Have a life outside of your job.
4. Avoid tobacco, alcohol, drugs, and excessive caffeine.
5. Draw strength from faith, friends, and family.
6. Maintain your sense of humor.
7. Have a personal preparedness plan.
8. Participate in training offered at your workplace.
9. Get a regular physical check-up.
10. Ask for help if you need it.

Some additional basic techniques are to make a daily plan and follow it; to reduce the changes in one's life (if possible); to handle one situation at a time; to have realistic self-goals; and to manage fear/anger. The management of fear and anger can be done by avoiding extreme reactions, practicing reassuring, comforting rituals, doing something for someone else, getting out of the stressful situation as quickly as possible, and talking with a professional counselor.

Effective stress management includes the concept of resilience. Resilience is ordinary and can help us cope with the difficulties and adversities of life. We can learn resilience in our own unique ways through the personal application of time and effort; however, resilience is not a guarantee against difficult times (Masten, 2001).

The Discovery Health Channel and the American Psychological Association's packet, Aftermath: The Road to Resilience, outlines ten ways to build resilience (2002):

1. Making connections
2. Avoiding seeing crises as insurmountable
3. Accepting change as a part of living
4. Moving toward one's goals
5. Taking decisive actions
6. Looking for self-discovery opportunities
7. Nurturing a positive view of self
8. Keeping things in perspective
9. Maintaining a hopeful outlook
10. Taking care of self

Item 8, keeping things in perspective, can include examination of the organization's dynamics as well as the individual's dynamics (SAMSHA, 2006). The organization is examined on the dimensions of: (a) effective management structure and leadership, (b) clear purpose and goals, (c) functionally defined roles, (d) team support, and (e) plan for stress management. Individual dimensions include: (a) management of workload, (b) balanced lifestyle, (c) stress reduction strategies, and (d) self-awareness. The mental health professional can use these dimensions as an evaluation assessment of organizational and individual dynamics that are contributing to the stress of the individual. Item 10, taking care of self, which is the focus of this chapter, underscores the importance of the development of resilience in a mental health professional's life.

Specific Techniques

Specific individual stress management strategies include educative, relaxation, and related techniques, and cognitive-behavioral models (Kilburg, Nathan, & Thoreson, 1989). The educative strategies are those connected with workshops that typically involve information and experiential activities regarding stress management. For example, a workshop may have a component on body awareness using the acronym HALT. HALT is like a temperature gauge: It can remind the mental health professional not to become too Hungry, Angry, Lonely, or Tired, and to address each area as necessary for self-care. The relaxation techniques are those involving the areas of yoga, meditation, relaxation training, biofeedback, and the like. Cognitive-behavioral models are those that examine the person's ideas that encourage the disturbance.

One example of a cognitive-behavioral model is mindfulness: "observing, seeing one thing in the moment" (Marra, 2004, p. 100). Mindfulness is one of the three components of self-compassion; the other two components are self-kindness and a recognition of common human struggles (Neff, 2008). Note that mindfulness has a positive impact on the counseling skills and therapeutic relationships of counseling graduate students (Schure & Christopher, 2008).

Mindfulness strategies include being non-judgmental and active, being mindful of one thing at a time and of the moment, and being focused on our senses) (sound, smell, touch, visual, body, thought, feeling, taste) as well as descriptive of our experience (Marra, 2004). In emotional mindfulness, we specifically identify the emotion, examine how it is expressed in the body, determine thoughts about the emotion, track down environmental triggers, document our own behavior, and document our (and possibly others') follow-up reactions to our behavior (Marra, 2004).

Another technique that crosses both relaxation and cognitive-behavioral approaches is the use of humor. Humor may help us in four ways (Martin, 2007). First, humor may have stress-buffering effects. In part, this may be a result of our being able to change our perspective on a situation in terms of reference frame, a positive challenge, and having a sense of control. Second, humor may help us in terms of "enhancing social support, denying reality, venting aggressive feelings and providing distraction" (Martin, 2007, p. 285). Third, if we have a humorous perspective, we tend to be more realistic and flexible, have more and various coping strategies and defences (e.g., cognitive reframes and management of emotions), and view stress as less threatening cognitively. Fourth, humor may also be helpful emotionally in times of extreme and uncontrollable stress.

Humor, then, can be very helpful to the mental health professional in crisis situations. For example, when I was doing 9/11 disaster mental health work in New York, I had a client who was frustrated with a copy machine yell at me, "I'm not always this difficult!" This seemed like such an understatement in the context of the extreme disaster he was facing in his life that both he and I burst into laughter. Following the laughter I said to the client, "It only seems reasonable that you are frustrated with everything happening to you," and we both smiled. An exchange of humor between the mental health professional and the client needs to be very sensitively done. For example, it may be prudent to let the client introduce the humor. In the previous story, the client laughed first and I followed his lead with my laughter.

While humor may help during the crisis situation, it may also help both before and after the crisis situation. Humor can be useful prior to a situation, when the mental health professional intentionally brings some elements of humor (for oneself) into the crisis situation in an appropriate way (carrying around a humorous quote or silly cartoon in a billfold or purse) or uses the humorous element following the crisis situation (doing something silly or light-hearted after heavy emotional work).

The use of general or specific techniques for stress management and self-care in a crisis situation requires that we be realistic about our work within the current situation and specifically what we can do in the specific crisis situation being faced.

Fundamental Lessons and Strategies

Although techniques for self-care can be helpful, five fundamental lessons regarding self-care can also benefit us as mental health professionals (Norcross & Barnett, 2008). First, having guiding principles rather than techniques allows us to have broad strategies that can be adjusted to fit our situations and personal preferences. Second, we need to have a broad variety of strategies to draw on for self-care. Third, we need to remember that self-care is an interactive process between the person and the environment. Fourth, our self-care must fit us in terms of our unique emotional resources and vulnerabilities. Fifth, we must practice self-care both at work and away from work. Twelve strategies (Norcross & Barnett, 2008) that we can use as a guiding framework are:

1. Valuing the person of the psychotherapist: Make self-care a priority.
2. Refocusing on the rewards: Look at what is rewarding about being a mental health professional.
3. Recognizing the hazards: Remember that the profession has inherent stressors and work within that reality.
4. Minding the body: Meet the needs of the body.
5. Nurturing relationships: Ask ourselves: "Who has my back?"
6. Setting boundaries: Establish boundaries between ourselves and others as well as between professional and personal lives (with a transition ritual between them).
7. Reconstructing cognitions: Monitor internal dialogue and countertransference, with the adage of "Be gentle with yourself."
8. Sustaining healthy escapes: Ask ourselves, "How do I play?" and "How can I structure in that time?"
9. Creating a flourishing environment: Examine our work environment in terms of specific dimensions (workload, control, reward, sense of community, respect, similar values) and the comfort of work (safety, privacy, lighting, ventilation, furniture, aesthetics) and positively change that which we can.
10. Undergoing personal therapy: Use therapy as a way to examine and heal ourselves.
11. Cultivating spirituality and mission: Be able to "pull hope from heal" (p. 26).
12. Fostering creativity and growth: Have diverse activities as a part of our job; go to conferences, read, and have study groups.

See Exercise 9.5 for personal application of these strategies.

Community of Support

To be resilient, we need to have a community of support (Discovery Health Channel & APA, 2002). Nurturing relationships and flourishing environments that include a sense of community help us cope with stress personally and professionally. Being resilient and able to face adversity is fused with the quality of one's social networks (Hoff et al., 2009). We need, then, as mental health professionals, to examine our support networks to determine whether they have enough to help sustain us in the work we are facing. Some specific types of support are discussed here to assist in the mental health professional's self-assessment: defusing, debriefing, "having a buddy," and consultation with a supervisor, mentor, or colleague.

Defusing is the process of talking out the crisis-related experience (Weaver, 1995). This is often informal and unplanned. It needs to be positive, supportive, and without criticism; it must involve individuals who have experienced the crisis intensely, and it must encourage as few war stories as possible (Hartsough Myers, 1985). Mental health professionals can find it very helpful to have someone with whom they can quickly process a crisis situation that they handled.

Debriefing is a formal meeting that usually occurs somewhere between 24 and 72 hours after the crisis, with the focus being on addressing any of the emotional experiences left over from the event (Weaver, 1995). It may be helpful for the mental health professional to check in with other professionals regarding the current strains being experienced in handling the crisis situations.

Simply "having a buddy" in high-stress situations helps one cope. Norcross and Barnett (2008) exemplify the importance of this concept when they ask in their strategy of nurturing relationships, "Who has my back?" It is much easier to cope with stress when one has a buddy, personally or professionally, and when we can view another person as "on our side." This perspective, this sense of not being alone, can provide an oasis of support and nurturance even in the face of the greatest stressors. Mutual aid self-help groups can also be resources of support.

Consultation with a supervisor, mentor, or colleague can also reduce one's sense of aloneness and increase one's sense of support. Supervision can reduce the stress of a job (Kilburg, Nathan, & Thoreson, 1989). The mental health professional with a trusted supervisor, mentor, or colleague may feel deeply supported in addressing stress experienced with regard to personal or professional crises.

The following true-life case of self-care in response to personal and professional stress is punctuated in bold where sections of the text on self-care are reflected.

For three years a mental health professional in her 50s experienced a great amount of personal and professional stress. Three crises occurred during an eight-month period of time, and in response to this stress, the mental health professional began working from 4:30a.m. to 10p.m. Monday through Friday for five months, and then added the same work schedule to a Saturday or Sunday for two years. These were responsibilities that could not be avoided or delegated because of the nature of the crises.

During this time, many people told her she would collapse mentally and/or physically under the stress, or that she would collapse once it was over. The mental health professional was determined to discover ways to live with the personal and professional pressure, which she had not experienced before in her life.

Although she had never been an athlete, in response to the stress she began working out at a wellness center every day (except Sundays) from one and a quarter hours to one and a half hours and working out with a personal trainer three times a week (community support; personal life away from stressors). At the suggestion of her trainer, she, who had never boxed before, began boxing to cope with stress. She found that even though she could not hit anyone, she loved the motion she experienced when hitting a bag and hitting pads held by her trainer. She boxed for two years (physical activity). When an additional stressor was experienced at her workplace after two years, and her trainer asked her if she wanted to try hula hooping, she, who had never been able to hula hoop, began hula hooping to cope with the stress (physical activity).

Because she had never been able to hula hoop, the encouragement of the young people at the local wellness center meant a lot to her (community support). They said things such as, "You can do this," and "You have to practice to get better." It took her three months to learn to hula hoop ("Progress, not perfection"; "Responsible for the effort, not the outcome"). During that time, many strangers gave her advice on how to hula hoop, because she was so bad at it (community support). It also became a bridge between herself and others where, again, total strangers would tell her stories when they saw her hula hooping at the wellness center: "I used to be good at that," "I had a hula hoop that looked like…," or "I was a teenager when the hula hoop was invented" (community support).

So what does this story have to do with self-care? The mental health professional found that it was hard to take herself too seriously on a day that she had started by hula hooping (play; running interference with self; humor). She also found that she was so bad at hula hooping that she could not do anything or think about anything else when hula hooping other than hula hooping itself (mindfulness).

After three months, she learned to hula hoop—and two weeks later she broke her wrist badly and had to have surgery. One week after surgery, she discovered she could hula hoop with one hand and began practicing hula hooping daily, since it was one of the few forms of exercise she could still do with a broken wrist (physical exercise). Hula hooping gave her hope for recovery during the pain of the break, surgery, and rehabilitation (play; running interference with self; humor).

She began to take hula hooping into her professional presentations and her trainings of graduate students and mental health professionals over the next four months (during which her wrist was in a cast), using hula hooping as a metaphor for self-care. For example, during breaks in a summer class, she invited the students to hula hoop with her in the grassy area outside of the building in which she taught. She found that it invited in everyone a playfulness that she believed is critical to self-care. Because it was so out of the ordinary for typical discussions on self-care, it freed both her and participants to talk about self-care in a more realistic, fun perspective.

The professional in this case example is me, the author of this text. So much healing and so many delightful discussions on self-care resulted in my decision to include this personal disclosure in this text. It is an excellent example (but not ideal by any means) of self-care practiced in the face of significant stressors. A more detailed description of my journey is outlined in the article "Cultivating the Capacity for Joy through Therapists' Self-Care: Examples of Daily Practices" (Ersever, Atkins, & Miller, 2009).

This chapter summarized a philosophical and practical approach to self-care. Specific hazards of crisis work for the mental health professional were addressed. Both general and specific approaches to self-care were explored.

1. What are the interchangeable terms that can lead to burnout?
2. What role can humor play in coping with stress?
3. What are five fundamental lessons of self-care?

Case Study

Case Study 9.1

Bob is a new mental health professional at a mental health center, and he has been picking up on-call responsibilities at his work in the last six months. The center requires mental health professionals to be on-call for a week once every four weeks. Bob has a lot of responsibilities personally, with a new family (a second child born in the last four months) and a new house, and he felt overwhelmed when his employer announced two months into his job that all mental health professionals would now be required to take rotating on-call shifts in their area of expertise. Bob had not done any crisis intervention work prior to this job, and found that being on-call was generally stressful, and the phone calls and interventions were quite demanding in terms of their emotional urgency and the time they required.

1. How would you suggest that Bob generally approach his situation in terms of self-care?
2. In the event he needs to stay at his job, how would you suggest he practice self-care at work?
3. How might Bob practice self-care in his personal life, particularly during the week that he is on call?