Dear Mental Health Practitioners, Take Care of Yourselves: a Literature Review on Self-Care.

Stress, burnout, and professional impairment are prevalent among mental health professionals and can have a negative impact on their clinical work, whilst engagement in self-care can help promote therapist well-being. This literature review examines the role of self-care in the promotion of well-being among mental health practitioners. Specifically, empirical research is presented in relation to specific domains of self-care practice, including awareness, balance, flexibility, physical health, social support, and spirituality. Findings from this review underscore the importance of taking a proactive approach to self-care and, in particular, integrating self-care directly into clinical training programs and into the quality assurance processes of professional organizations within the field of mental health. © Springer Science+Business Media, LLC, part of Springer Nature 2019.

Introduction

Mental health practitioners (e.g., counselors; psychotherapists) work in a culture of one-way caring (Guy 2000) in which they are required to demonstrate empathy, compassion and patience, without the expectation of receiving such care in return from their clients (Skovholt et al. 2001). To be effective in providing mental health services, practitioners must develop a professional alliance or working relationship with clients that maintains appropriate boundaries and levels of emotional or psychological involvement, and to do so consistently from one client to another (Skovholt and Trotter-Mathison 2011). Establishing and maintaining these one-way working relationships takes significant effort and energy (Skovholt and Trotter-Mathison 2011) placing practitioners at increased risk for negative outcomes such as stress (El-Ghoroury et al. 2012), burnout (Wityk 2003), and professional impairment (Harrison and Westwood 2009). Ironically, while helping clients move toward well-being, practitioners often can overlook their own needs (Barnett et al. 2007) and indeed may not have “learned how to take the time to care and to nourish [themselves], having been trained to believe that this would be selfish” (Sapienza and Bugental 2000, p. 459). As a result, engaging in self-care can often sit at the end of a practitioner’s to-do list, rather than being made a priority.

Yet self-care, or attending to one’s own holistic well-being, can be a pathway towards preventing negative outcomes such as burnout (Barnett et al. 2007). Experienced therapists support including self-care as a primary objective for mental health practitioners (Jennings and Skovholt 1999; Thériault et al. 2015) and this should be recognized as a fundamental part of functioning in a helping career (Guy 2000). The practitioner is a “powerful but vulnerable tool in the caring process” that requires attention and care (Sansó et al. 2015, p. 204) in order to prevent not only practitioner ill-health (Butler et al. 2017; Stebnicki 2007), but also negative consequences for the clients they serve (Bearse et al. 2013). In fact, mental health practitioners have an ethical duty to provide responsible caring, maximizing benefits and minimizing harm for their clients. In order to provide effective care to their clients, practitioners must first be well themselves (Norcross and Guy 2007). To promote responsible caring, several regulating bodies have, therefore, included practitioner self-care in their code of ethics. For instance, section II.12 of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association 2017) states that, in accordance with the Principle of Responsible Caring, members are to “engage in self-care activities that help to avoid conditions (e.g., burnout, addictions) that could result in impaired judgment and interfere with their ability to benefit and not harm others”. Regulatory bodies thus understand self-care as being an ethical obligation for the mental health professional.

The purpose of this literature review was to examine the role of self-care within the context of mental health professions (counseling, psychotherapy, etc.). Specifically, this review will cover the following topics: negative health issues (e.g., burnout) for mental health practitioners; definition of self-care; types of self-care (e.g., life balance, spirituality) and their empirical support; and implications for the integration of self-care within training programs and professional organizations.

The Downside of Mental Health Professions

Stress among mental health professionals has been a known issue for decades, since Freud (1937/1963) discussed the stressfulness of therapist uncertainty around the issue of therapeutic success. For example, psychologists experience stressors in relation to the heavy emotional demands associated with clients’ presentations including client lack of improvement, symptom relapse, suicide ideation and attempts, aggressive or violent behaviours, as well as the practical demands related to paperwork, ethical practice, licensing, malpractice complaints, and professional isolation (Barnett et al. 2007). Bettney (2017) also identified the work-related issues of large caseloads and negative team environments as being additional stressors for mental health practitioners. Given the presence of such multiple stressors, it is no wonder that practitioners, including graduate trainees, report a high level of stress and distress (El-Ghoroury et al. 2012; McKinzie et al. 2006; Myers et al. 2012). For example, 73% of Australian psychology postgraduate trainees reported clinically significant levels of distress (Pakenham and Stafford-Brown 2012). To complicate matters, mental health practitioners may not be fully aware of the impact of these various profession-related stressors and so will be less likely to see the need to engage in preventative measures (Barnett et al. 2007), or to seek treatment once the stressors have taken a toll (El-Ghoroury et al. 2012). Research has shown that for trauma therapists, work-related stress is related to their use of avoidant coping strategies, such as denial (Killian 2008). Unfortunately, left unresolved, work stress can set the stage for more serious issues, such as burnout and professional impairment to emerge (Barnett et al. 2007; Clark et al. 2009).

Burnout is described in terms of emotional exhaustion, depersonalization (Killian 2008), diminished self-efficacy (Stebnicki 2007), and reduced personal accomplishment (Clark et al. 2009). Burnout among mental health practitioners is more difficult to treat than general work stress (Dreison et al. 2018), highlighting the need for prevention or early treatment. Unfortunately, the prevalence of burnout among mental health professionals is significant. In one study, 13% of behavioral health providers were at risk of compassion fatigue or burnout (Sprang et al. 2007), while 49% of counselling or clinical trainees reported experiencing burnout (Kaeding et al. 2017). Burnout can lead to poor quality of life (Chang 2014) as it is associated with a variety of mental and physical health problems, including headaches, muscular pain, and depression (Ahola et al. 2007; Vlăduţ and Kállay 2010). In turn, practitioner burnout affects overall therapeutic effectiveness (Bearse et al. 2013), not only reducing the level of care provided by the practitioner, but potentially leading to more serious inappropriate behaviours that can be harmful to clients. For example, Rupert and Kent (2007) found that psychologists’ emotional exhaustion and depersonalization of clients, two aspects of burnout, were related to practitioner over-involvement with clients and clients engaging in negative behaviours.

The cumulative effects of emotional, mental, and physical burnout thus can lead to professional impairment in the provision of services (Figley 2002). The potential for professional impairment is particularly increased for practitioners who work in the field of trauma, and is known variously as “secondary victimization” (Figley 1988), “vicarious traumatization” (McCann and Pearlman 1990), “compassion fatigue” (Figley 1995), and “empathy fatigue” (Stebnicki 1999). Vicarious traumatization, for example, has been recognized as a distinct occupational hazard for mental health professionals (Buchanan et al. 2006), as it can affect self-worth, identity, world view, basic beliefs, psychological needs, perception, and memory (Saakvitne 2002) and hinder or impair the practitioner’s initiatives towards professional development, personal growth, and holistic well-being (Stebnicki 2007). This type of counsellor impairment can significantly compromise therapeutic work, and pose harm to clients (Johnson et al. 2018; Lawson 2007). Given that both practitioner and client well-being are at risk when mental health professionals experience burnout, it is vital that steps are taken to address this issue (Barnett and Cooper 2009). Unfortunately, research has shown that interventions in reaction to practitioner burnout seem to demonstrate limited or no positive impact on the mental health of practitioners (Van Dam et al. 2011), thus shifting the spotlight toward preventative measures as a more desirable action.

The Upside: Self-Care as Prevention

There is substantial support for the beneficial effects of self-care practice in the reduction of negative outcomes such as burnout for mental health practitioners. While a lack of self-care is related to higher levels of burnout and secondary traumatic stress symptoms, a greater risk of health status decline, and the experience of stress (Butler et al. 2017; Mayorga et al. 2015; Santana and Fouad 2017), engagement in self-care is associated with greater well-being (Colman et al. 2016), lower levels of stress and negative affect, higher levels of positive affect, flourishing, self-rated academic, and clinical performance (Zahniser et al. 2017), compassion satisfaction (Butler et al. 2017), and quality of life (Goncher et al. 2013). Overall, engagement in career-sustaining behaviours is linked to a greater sense of personal accomplishment and a lesser tendency to depersonalize clients (Rupert and Kent 2007). In fact, experienced mental health practitioners, or those who might be called “master therapists”, refer to self-care as a key aspect of professional functioning. Jennings and Skovholt (1999) report that such master therapists prioritize self-care in their profession and take “preventative action to protect what they consider [to be] their most important therapeutic tool: themselves (p.7)”. Further, Dorociak et al. (2017b) found that more experienced practitioners engage in more self-care behaviours and report less stress than practitioners who are early in their career.

What Is Self-Care?

Self-care refers to the “ability to refill and refuel oneself in healthy ways” (Gentry 2002, p. 48), including “engagement in behaviours that maintain and promote physical and emotional well-being” (Myers et al. 2012, p. 56) and that “lessen the amount of stress, anxiety, or emotional reaction experienced when working with clients” (Williams et al. 2010, p. 322). The term self-care refers not only to an engagement in various practices but also to having a caring attitude or ‘being’ caring toward oneself (Kissil and Niño 2017). Self-care involves self-reflection and action in terms of knowing one’s needs and making a conscious effort to seek out resources that will foster health and well-being (Colman et al. 2016; Pakenham 2017). Self-care is not a luxury but is a clinical and ethical imperative in the mental health professions (Norcross and Guy 2007) and so it is important to understand the potential effectiveness of various forms of self-care practices.

What Works?

Mental health practitioners often use a variety of self-care practices that address areas of awareness, balance, flexibility, physical health, social support, or spirituality.

Awareness

First, awareness involves having knowledge about what it means to be a mental health professional, including an understanding of the risks for and symptoms of burnout and professional impairment (Smith and Moss 2009; Wityk 2003). Practitioners also have to hold realistic expectations about the nature of the work they do and an understanding of how to assess the effectiveness of such work (Skovholt et al. 2001; Thériault et al. 2015). Barnett et al. (2007) encourage mental health professionals to view themselves as being vulnerable to the personal and professional stressors of their career, as it is only with this awareness that preventative measures are likely to be taken. When practitioners are aware of work stressors such as isolation (Barnett and Cooper 2009), they can make a conscious effort to behave in ways that overcome or avoid such stressors, such as by planning and participating in regular case consultations with colleagues.

Second, awareness refers to noticing and reflecting on one’s internal and external experiences, and monitoring one’s own needs (Skovholt et al. 2001; Wityk 2003). This awareness of the self is a conscious and continuous process (Harrison and Westwood 2009). Practitioners must be aware of the many dynamics operating in the therapy room, including what is happening within the client, within themselves, and within the therapeutic interaction between them (Sansó et al. 2015; Williams et al. 2003). As psychotherapeutic work can involve resistant clients, slow change/growth, and discussing primarily negative content (Norcross and Guy 2007), it is important that mental health professionals notice when they are feeling drained and take action to replenish their mental health (Sansó et al. 2015).

Experienced practitioners emphasize the importance of self-reflection to their optimal development as a mental health professional (Rønnestad and Skovholt 2001). The more self-aware a practitioner is, the more likely they are to recognize and attend to their needs (Norcross and Guy 2007), which in turn allows them to provide quality services (Lawson 2007). Essentially, “the better we know ourselves, the better we can know and be helpful to others” (Silverman 2008, p. 92). It was found by Zahniser et al. (2017) that psychology doctoral students who demonstrated cognitive self-awareness engaged in more effective self-care than those who did not. Self-monitoring and awareness have also been related to practitioners experiencing lower levels of emotional exhaustion (Rupert and Kent 2007), burnout and compassion fatigue, a greater sense of gratification in their work, and an ability to maintain emotional balance in difficult situations (Sansó et al. 2015). In contrast, a lack of self-awareness of issues of therapeutic process (e.g., countertransference) is linked to greater burnout (Chang 2014).

Researchers have recommended a variety of methods for improving awareness among mental health practitioners, including participation in an Acceptance and Commitment Therapy course (Pakenham 2017), mindfulness and meditation training (Boellinghaus et al. 2013) and self-reflection (Knapp et al. 2017; Ng et al. 2017). Creative writing is another practice that has been recommended to foster awareness among counsellors (Warren et al. 2010). While it has been argued that “too much” self-awareness can hinder professional work by distracting the practitioner during a therapy session (Williams et al. 2003), the literature generally supports the need for mental health professionals to practice on-going self-awareness of their experiences (Barnett et al. 2007).

Balance

Balance is defined as “a state reflecting satisfaction or fulfillment in several important domains with little or no negative affect in other domains” (Sirgy and Wu 2009, p. 185) and is considered by practitioners to be one of the most important areas of self-care (Stevanovic and Rupert 2004). Balance refers to distributing one’s attention to various aspects of life, ensuring not to neglect important facets, and to maintaining a sense of equilibrium in both personal and professional realms, whereas imbalance occurs when satisfaction in one domain leads to negative outcomes in other domains (Sirgy and Wu 2009). Maintaining balance between different life domains is frequently recommended in the self-care literature (e.g., Backman 2004; Lee et al. 2009), while seeking balance within the work domain is also important (Harrison and Westwood 2009). Specifically, a resilient practitioner is one who can create balance between other- and self-care across life domains (Skovholt and Trotter-Mathison 2011). Research has shown that work-life imbalance (e.g., high case load; workaholism) is related to the experience of work stress and compassion fatigue (Killian 2008). Poor work-life balance has also been linked to exhaustion among mental health practitioners (Scanlan et al. 2013) and feelings of anxiety, stress, and being unsettled (Hill et al. 2016). In contrast, maintaining balance in life is related to lower levels of emotional exhaustion (Rupert and Kent 2007), greater career satisfaction (Rupert et al. 2012), and lower risk of burnout (Levin et al. 2017).

In terms of strategies to achieve balance, leisure time in particular is considered to be a key component of self-care (Grafanaki et al. 2005; Nurit and Michal 2003; Patsiopoulos and Buchanan 2011), as well as engaging in a variety of professional activities (e.g., teaching), in addition to client work (Harrison and Westwood 2009). Other strategies to achieve life balance include: cultivating non-work-related passions, interests, and relationships, having a holistic view of well-being, limiting scope of practice when coping with significant personal life events, maintaining good work and personal life boundaries, using time management skills, taking needed breaks, having flexible work hours and locations, setting realistic work goals, and turning to spirituality (Lee et al. 2009; Matheson and Rosen 2012; Thériault et al. 2015).

Flexibility

Although flexibility is an important aspect of self-care, it has not been widely researched, due in part to a lack of a clear definition of what flexibility entails (Kashdan 2010). The term flexibility refers to a number of dynamic processes, including practitioners’ utilization of effective coping strategies and to their openness and ability to adapt to and grow from life stress (Kashdan 2010). Fostering attitudes and engaging in practices that promote healthy coping and ongoing growth can be thought of as forms of self-care as they promote well-being (Wise et al. 2012), and can be helpful in the prevention of negative outcomes (Knapp et al. 2017).

Mental health professionals face a variety of challenges throughout their careers (Norcross and Guy 2007). For example, it can be riddled with inconsistency, unanticipated challenges such as clients in crisis, and disappointments including slow progression or lack of therapeutic success, which often are not within the therapist’s control (Negash and Sahin 2011; Smith and Moss 2009). Confronted with such demands, having an inflexible coping response style can have a negative impact on practitioners’ well-being and growth. Kaeding et al. (2017) found that counselling trainees who hold rigid, perfectionistic expectations about their performance report experiencing greater burnout. High performance standards in combination with low self-efficacy is also related to problematic emotion regulation, neuroticism, and high cortisol levels (Richardson et al. 2014). What complicates matters is that mental health practitioners essentially are required to suppress or control their emotional reactions and limit self-disclosure in order not to interfere with the therapeutic process (Guy 2000). While some research suggests expressive suppression may be beneficial in the short-term (Myers et al. 2012), it has also been associated with negative outcomes for the therapist, such as increased anxiety and depression (Moore et al. 2008), and to higher levels of stress (Finlay-Jones et al. 2015).

To prevent the negative outcomes associated with the inevitable challenges of this career, practitioners need to find ways to internally manage and externally respond to the varying demands of their work. Practitioner flexibility in attending to and regulating their emotions is beneficial for their well-being (Miller and Sprang 2017; Pletzer et al. 2015).

For example, the emotion regulation technique of cognitive reappraisal is linked to better well-being and as such appears to be a more adaptive strategy than expressive suppression (Gross and John 2003). Specifically, practitioners who reappraise events report more positive and less negative emotions as well as better interpersonal functioning. In addition, psychologists and post-graduate psychologist trainees who hold an attitude of self-compassion report fewer difficulties in emotion regulation (Finlay-Jones et al. 2015). Having an attitude of self-compassion and acceptance helps therapists to recognize and address their professional limitations (Patsiopoulos and Buchanan 2011). In fact, engaging in professional development on a regular basis is recommended for therapist self-care (Knapp et al. 2017), and is increasingly being made mandatory by professional associations. Other practices that can promote flexibility are setting and reappraising goals (Wityk 2003), engaging in expressive writing or journaling (Baddeley and Pennebaker 2011; Warren et al. 2010), and engaging in Acceptance and Commitment Therapy (Rudaz et al. 2017).

Physical Health

Self-care in relation to physical health encompasses a focus on issues of sleep, exercise, and diet (Harrison and Westwood 2009). Due to the sedentary nature of therapy work, practitioners can experience physical health concerns (Smith et al. 2014), with tiredness, and neck and back pain being the most frequently reported physical health symptoms by psychologists in training (Kaeding et al. 2017). In another study, clinical graduate students reported greater fatigue and more frequent headaches, back pain, and irritable bowel symptoms on a bi-weekly basis, as compared to the general population (Rummell 2015). In turn, physical health problems can have a negative impact on practitioners’ client work, especially in regard to the therapeutic alliance (Kim et al. 2011).

Sleep issues are prevalent among mental health practitioners. In a study by Schlarb et al. (2012) 44 % of psychotherapists were found to be suffering from symptoms of insomnia. Stress significantly reduces the quantity and quality of sleep, with poor sleep in turn triggering greater stress the next day (Åkerstedt et al. 2007). Insufficient sleep is linked to exhaustion and low professional efficacy (Wolf and Rosenstock 2017), higher levels of stress (McKinzie et al. 2006) and clinical levels of burnout (Söderström et al. 2012). For example, nurses who slept less than six hours per working day had a higher risk of job strain and burnout (Chin et al. 2015). Further, sleep deprived individuals tend to select less demanding challenges and tasks (Engle-Friedman et al. 2003), and so mental health practitioners may not be providing their best care for clients.

To prevent negative outcomes such as burnout, practitioners can actively engage in sleep hygiene techniques. Maintaining a regular sleep schedule and getting ample sleep each night is recommended to promote well-being (Barnett et al. 2007). Specifically, self-monitoring sleep habits is an effective method of improving sleep hygiene (Mairs and Mullan 2015). Other effective sleep hygiene techniques include maintaining a regular sleep schedule, making one’s sleep environment restful, and avoiding going to bed hungry or thirsty (Mairs and Mullan 2015).

Exercise and diet are equally critical components of self-care. Psychologists often recommend a balanced diet and physical activity to their clients (Burton et al. 2010); however, it is unclear how dedicated they are to this aspect of their own self-care (Norcross and Guy 2007) – even though maintaining a healthy lifestyle is ranked as the fourth most important self-care practice by experienced therapists (Thériault et al. 2015). In addition to maintaining a balanced diet and attending to hydration on a daily basis, it is recommended that mental health practitioners exercise regularly (Harrison and Westwood 2009). Empirical research on helping professionals and general populations highlight the psychological benefits of physical health. For example, medical students who exercise, regularly reported less exhaustion and greater professional efficacy (Wolf and Rosenstock 2017), and lower rates of burnout and higher quality of life (Dyrbye et al. 2017). Physical health may serve as a protective factor in relation to the well-being of practitioners. For example, Gerber et al. (2014) found that undergraduate students who engaged in vigorous physical activity experienced less stress and pain and fewer sleep problems and depressive symptoms at stressful times than those who did not. In another study, individuals who had moderate to high fitness scores reported fewer symptoms of burnout and depression than those who had low scores (Gerber et al. 2013). In contrast, one study actually found a positive relationship between exercise and the experience of stress among clinical graduate students (McKinzie et al. 2006). Perhaps in regard to the study, rather than contributing to stress levels, individuals may have engaged in more exercise as a means of coping under times of greater stress.

Social Support

Social support refers to “the resources and interactions provided by others and/or the connection to others that help one cope with stressful circumstances…[that] can come from a variety of sources, including family, friends, co-workers, supervisors…” (Clark et al. 2009, p. 582). Given that isolation is a known risk factor for burnout among mental health practitioners (Stebnicki 2007), research has focused on the role of personal and professional social support in self-care. Practitioners rely on many sources of support, including peer support, individual and/or group supervision, involvement in professional associations, colleague assistance programs, and personal therapy (Barnett et al. 2007). While some studies have suggested that social support is of little importance to mental health professionals (e.g., Stevanovic and Rupert 2004), others have found it to be a significant factor in practitioners’ well-being. For example, Killian (2008) found that social support was the most significant predictor of compassion satisfaction among trauma therapists. Strong social support is related to lower levels of perceived stress (Myers et al. 2012), while a lower level of personal (e.g., family) and professional (e.g., collegial) support is linked to greater psychological distress (Nelson et al. 2001).

Personal support (i.e., friends, family, personal therapy) is a valuable element of self-care and a way to promote life balance for practitioners (Barnett et al. 2007) and may be more important than other types of support (e.g., peers, professors) for graduate counselling students (Tompkins et al. 2016). Psychology graduate students often more frequently seek out personal support and rate these relationships as most effective in addressing personal and professional stress (El-Ghoroury et al. 2012; Nelson et al. 2001). Satisfaction with personal support is linked to greater self-esteem, psychological adaption (i.e., flexibility), and professional functioning, lower anxiety and depression, and less use of avoidance coping among clinical trainees (Kuyken et al. 2003). In contrast, Rupert and Kent (2007) found that psychologists who discussed their work frustrations with spouses and colleagues reported higher levels of emotional exhaustion. Although this finding might suggest a negative spillover of work stress into the personal life domain, it may also reveal that psychologists often seek support from outside sources when they are exhausted from work demands. Finally, personal therapy is recommended as a method of self-care (Thériault et al. 2015). Unfortunately, there are many barriers to mental health practitioners seeking therapy, with concerns about confidentiality, cost, and time being identified as the most common obstacles (Dearing et al. 2005). One study revealed that 59% of professional psychologists did not seek therapy despite knowing it would be to their benefit (Bearse et al. 2013).

Practitioners can also seek professional support from clinical supervisors, mentors, advisors, professional colleagues/peers, and professors. Experienced therapists place professional and peer supervision within the top three most important and useful coping strategies for managing self-care and feelings of incompetence (Thériault et al. 2015). Zahniser et al. (2017) found that professional support had a number of benefits for clinical psychology students, including increasing professional development, life and daily balance, cognitive awareness, flourishing, positive affect, progress in clinical and academic work, and reducing perceived stress and negative affect. Professional support is not only a highly recommended practice for self-care, but methods such as supervision have become a mandatory requirement of many mental health professions (e.g., the Canadian Counselling and Psychotherapists Association; the American Counseling Association; the College of Registered Psychotherapists of Ontario).

In particular, clinical supervision can be a resource for increasing awareness of the risks and symptoms of negative outcomes experienced by mental health practitioners, while at the same time providing a safe space for such symptoms to be recognized (Merriman 2015). In fact, Merriman (2015) argues that ideally supervision should include the development and monitoring of self-care plans for supervisees. In addition to supporting supervisee competence (Bradshaw et al. 2007), supervision can help serve to identify gaps in training, provide checks on caseload and work-life balance, direct career development, encourage self-care, and serve as a support when supervisees face professional hazards (Pack 2015). Clinical psychology graduate students report being most satisfied with their supervisors when they receive advice on self-care and work-life balance (Peluso et al. 2011). In turn, work-based social support, such as supervision, helps trainees use adaptive coping styles (Kuyken et al. 2003).

The effects of supervision also reach beyond the supervisee to have an impact on the supervisee’s therapy with clients. Bambling et al. (2006) found that clients receiving help from supervised therapists showed significantly stronger working alliances, larger reductions in depression scores, greater treatment retention, and higher treatment satisfaction than those whose therapists were unsupervised. In contrast, some studies have shown professional support to have a negative impact on mental health practitioners. For example, Clark et al. (2009) found that advisor support was a predictor of burnout. They proposed that the hierarchical nature of supervision, and students and practitioners’ fears that they were not living up to their advisors’ expectations may induce stress that leads to burnout. This finding emphasizes the need for a strong alliance between supervisee and supervisor (Peluso et al. 2011).

Peer support and collaboration uniquely sits somewhere between the realms of professional and personal social support in that it is less hierarchical and as such can create space for self-care both in and outside the workplace (Barlow and Phelan 2007). Peer consultation can help practitioners address biases about competence, help prevent therapists drifting away from therapeutic models, and positively impact practitioner burnout and anxiety (Waltman et al. 2016). Further, socioemotional support from faculty members has been seen to be related to graduate students’ program and overall life satisfaction (Tompkins et al. 2016), while professional association involvement can help identify issues of professional impairment and address matters related to practitioners’ mental, physical, and spiritual well-being (Stebnicki 2007).

Spirituality

Pargament (1999, p. 12) defines spirituality as “a search for the sacred” in one’s life that encompasses aspects of connection with self, others, and the divine, as well as purpose and ultimate meaning. Experienced therapists describe how a sense of spiritual connection sustains their professional efforts and helps to dispel feelings of isolation and despair (Harrison and Westwood 2009). Specifically, these therapists are “comforted by the belief that they are a part of something larger, meaningful, and good, that they are not alone in their efforts, and that these are not futile” (p. 209). Experienced (master) therapists interviewed by Jennings and Skovholt (1999) also noted how the practice of spirituality was essential to their mental health and emotional well-being. Mindfulness (Hemanth and Fisher 2015) and making meaning in work (Norcross and Guy 2007) are two main practices that have been linked to practitioner spiritual self-care. Other spiritual practices utilized by mental health professionals include prayer (Moore et al. 2011) and spending time in nature (Grafanaki 2005; Patsiopoulos and Buchanan 2011).

As a spiritual practice, mindfulness is defined as “a type of awareness that entails being fully conscious of present-moment experience and attending to thoughts, emotions, and sensations as they arise without judgment and with equanimity” (Christopher and Maris 2010, p. 115). Expert therapists have identified mindfulness as a way to enhance clinician awareness, acceptance of limitations, and clarity about self in relation to others (Harrison and Westwood 2009). Counselling students who receive mindfulness training report greater physical, emotional, and interpersonal well-being (Christopher and Maris 2010) and that these effects continue as graduates transition into the professional workforce (Christopher et al. 2011). Mindfulness training also helps clinical trainees cope more effectively with difficult experiences (Hemanth and Fisher 2015). Mindfulness-based stress-reduction is related to lower levels of perceived stress, negative affect, state and trait anxiety, rumination, and higher levels of positive affect and self-compassion (Shapiro et al. 2007), as well as to improved clinical skills such as empathy that in turn may reduce the risk of harm to clients (Leppma and Young 2016; Schomaker and Ricard 2015). Professional psychotherapists who use mindfulness report improvements in their levels of attention, self-awareness, self-compassion, capacity for empathy, and ability to tolerate difficult emotions (Keane 2014).

A relationship between mindfulness and lower levels of burnout among psychotherapists has also been established (Di Benedetto and Swadling 2014). That said, others have found mindfulness training to have no effect on the stress levels of graduate students (Myers et al. 2012) or having an effect on stress but not on burnout symptoms (Suyi et al. 2017). From a meta-analysis of the literature, Rudaz et al. (2017) concluded that mindfulness training seems to have a beneficial effect on stress levels, while the results on burnout, self-compassion, and psychological well-being are varied. Thus, it is important to establish and understand just what components of mindfulness are effective in this context.

The process of meaning-making has three components: (1) interpreting an event through the lens of personal values and beliefs (i.e., positive reappraisal); (2) setting goals that engender a sense of life purpose and personal control; and (3) calling on spiritual beliefs and activities in order to address existential issues and to find ultimate meaning (Folkman 1997). The objective of meaning-making is to reduce the discrepancy between the appraised meaning of a situation and the individual’s global beliefs and goals (Park 2010). As a deliberate practice (Park 2010), meaning-making serves as another pathway to self-care for mental health practitioners. This process encourages practitioners to situate their stressors within their overarching values and belief system, recall their purpose of working in this field, and connect with the transcendent or the ultimate meaning of their work. As Norcross and Guy (2007) explain, “to be present at the moment of significant insight or decision in the life of a client is a spiritual experience that connects the psychotherapist to the flow of life and creation” (p. 21).

Practitioners are encouraged to engage in meaningful work as a form of self-care (Dombo and Gray 2013; Ng et al. 2017). Pakenham (2017) proposes that awareness of one’s values can play a key role in motivating clinical psychology trainees to engage in behaviours that are fulfilling and that the connection with one’s personal and professional values plays a role in the maintenance of well-being. Norcross et al. (2005) encourage practitioners to revisit what initially led them to choose a career in mental health in order to reawaken their sense of purpose and thus revitalize their spirit for this field of work. Specifically, practitioners who practice gratitude and internalize the rewards of working in mental health move toward positive well-being and away from negative outcomes such as burnout (Norcross and Guy 2007). Mason (2016) suggests that meaning-making can interrupt therapists’ experiences of compassion fatigue and burnout. Having a sense of meaning and existential well-being in relation to one’s work is associated with lower levels of depression (Eakman 2016), less stress and more social support (Calicchia and Graham 2006), greater career satisfaction (Rupert et al. 2012), joy (Pooler et al. 2014), and less burnout and fewer psychiatric symptoms (Currier et al. 2013). For example, neurology residents and fellows who reported meaning in their work were more likely to experience career satisfaction and be at lower risk for burnout (Levin et al. 2017).

Discussion

This literature review revealed that the high prevalence of stress (Killian 2008), burnout (Kaeding et al. 2017), and professional impairment (Buchanan et al. 2006) among mental health professionals makes the need for action abundantly clear. As treating these negative outcomes reactively seems difficult (Van Dam et al. 2011), attention might be better focused on prevention. Self-care is recommended as a preventative approach by occupational health researchers (Barnett et al. 2007) and master therapists (Jennings and Skovholt 1999), and has been supported by empirical research (Colman et al. 2016; Santana and Fouad 2017). Self-care as an ongoing practice is a method for not only preventing negative outcomes among mental health practitioners and their clients, but also appears to promote flourishing (Wise et al. 2012). This review of the literature suggests that fostering areas of self-care, including awareness, balance, flexibility, physical health, social support, and spirituality (see Table 1), can help prevent the downward spiral of stress, burnout, and professional impairment, and promote an upward spiral of well-being for mental health professionals (see Fig. 1).

Table 1

Self-care strategies for mental health practitioners

Self-care domains	Self-care strategies
Awareness	Acceptance and Commitment Therapy
	Mindfulness and meditation training
	Self-reflection
	Creative writing
Balance	Leisure activities
	Varied work activities (e.g., teaching)
	Non-work related passions
	Non-work related relationships
	Holistic approach to health
	Professional and personal boundaries
	Time management
	Taking breaks
	Flexible work hours and locations
	Realistic work goals
Flexibility	Effective coping strategies
	Attitude of openness
	Adaptability
	Realistic self-expectations
	Cognitive reappraisal
	Self-compassion and acceptance
	Setting and reappraising goals
	Expressive writing and journaling
	Acceptance and Commitment Therapy
	Professional development
Physical health	Sleep hygiene (e.g., self-monitoring sleep habits)
	Balanced diet and hydration
	Exercise
Social support	Personal:
	Family
	Friends
	Personal psychotherapy
	Professional:
	Individual or group supervision
	Professional associations
	Colleague assistance programs
	University faculty
	Mentors/advisors
	Peer consultation
Spirituality	Spiritual connection
	Prayer
	Mindfulness
	Spending time in nature
	Practicing gratitude
	Meaning-making:
	Positive reappraisal
	Engaging in meaningful work
	Setting goals with life purpose
	Spiritual beliefs and activities (e.g., ultimate meaning of work)

Fig. 1

Self-care in the promotion of the well-being of mental health practitioners

While there is a growing abundance of empirical studies and expert commentaries on self-care, less is written about how to integrate holistic self-care into the lives of mental health practitioners. Just as therapists incorporate research on therapeutic interventions into their practice with clients, findings on self-care need to be promulgated more actively to practitioners in the mental health field. First, it is critical to integrate self-care more pro-actively into clinical training programs, given that trainees experience significant stress in their programs that may carry over into their transition to work (Robins et al. 2018). Students need to be able to maintain their competence to engage as mental health practitioners and to meet the demands for self-care as required by professional associations. Although many universities in Australia, for example, recommend creating and modelling a culture of self-care for trainees (Perry et al. 2017), unfortunately, self-care is not often formally taught or discussed within clinical training programs. In their review of 136 handbooks from clinical psychology doctoral programs, Bamonti et al. (2014) found that only 8.4% of general psychology handbooks and 24.8% of clinical psychology handbooks included a reference to self-care, and that they primarily informed already impaired students about services available. In the APA Advisory Committee on Colleague Assistance’s survey of graduate student stress, alarmingly low rates of self-care training were found (Munsey 2006). Eighty-three percent of students reported that their training program did not offer written material on self-care, 63% that their training program did not sponsor activities promoting self-care, and 60% that their training program did not informally promote an atmosphere of self-care.

Such findings suggest that many accredited training programs are neither fully attending to the needs of students, nor upholding the ethical obligations for self-care required by professional associations. Such neglect may lead to the potential for harm, not only for the student trainee but for the clients with whom they work. Pakenham (2017) suggests that building efficacy in self-care early on is an important step in developing strong self-care skills among mental health practitioners. As students experience the positive results of adopting an attitude of self-care and actively engage in self-care practices, they are more likely to continue to use such strategies in their future work. Indeed, students who are in clinical training programs that promote self-care report greater benefits (Roach and Young 2007).

Second, as self-care is a dynamic process and practices used by mental health practitioners will be adopted throughout the span of their practice (Dorociak et al. 2017a), it may be helpful for professional organizations to provide information on empirically-supported strategies for self-care. For example, a guideline of areas in practitioners’ personal and professional lives that need attention could be part of ethical practice and may help highlight gaps in self-care. Having members complete a self-care inventory as part of annual certification renewal processes could also help prevent negative outcomes by increasing awareness and promoting self-care behaviours. Finally, providing and promoting training in areas of self-care (e.g., time-management, ethical assertiveness, mindfulness) could help mental health practitioners to better integrate self-care attitudes and practices.

Limitations in the Literature

Although there is much research in the area of the self-care of mental health practitioners, limitations exist in this field of study. First, while experienced practitioners seem to endorse all of the areas mentioned in this review (Norcross and Guy 2007), research has focused primarily on awareness, balance, social support, and mindfulness and less so on flexibility, meaning-making, and physical health. This imbalance in research focus may reflect a lack of clear definition for the construct under study (e.g., flexibility). Some areas of self-care can overlap (e.g., flexibility and balance) making it difficult to distinguish their unique contributions to well-being. For example, balance can be achieved through the perception of meaning in occupation (Eakman 2016), while mindfulness as a technique promotes awareness (Rudaz et al. 2017). Second, some constructs may be simply taken for granted as an aspect of self-care as they are relevant to the well-being of all persons not just mental health practitioners (e.g., physical health). Third, self-care most commonly is studied in relation to the well-being of practitioner trainees such as graduate students in clinical psychology programs. While this population represents individuals who are actively providing mental health services, it may be somewhat biased in that graduate students tend to experience higher levels of stress and other negative symptoms due to the multiple demands of this career phase (Myers et al. 2012).

Future Directions

Self-care training should include introducing areas that have received empirical support. While practitioners’ use of flexibility and spirituality (specifically mindfulness) would benefit from further research, the general findings from this literature review suggests that including areas of awareness, balance, flexibility, physical health, social support, and spirituality in self-care training would allow for a holistic education on the topic. Encouraging specific practices that fit within each of these categories and yet meet the unique needs of practitioners would be optimal. Longitudinal studies would provide a better understanding of the nature and efficacy of self-care (Pakenham 2017) across practitioners’ career trajectory. Meta-analyses of various self-care practices would also help advance understanding of which techniques are most effective and should be prioritized in future research and training.

Conclusion

Training programs and professional organizations have the power to cultivate an attitude of self-care in the field of mental health work. The current literature suggests that a proactive stance toward self-care can help reduce negative outcomes experienced by mental health practitioners (Goncher et al. 2013), and improve the care of clients (Schomaker and Ricard 2015), both being ethical imperatives in the profession. The vast increase in published literature on self-care, and its inclusion in multiple codes of ethics demonstrates that a positive shift toward self-care has already begun, with, for example, two self-care scales being recently developed (Dorociak et al. 2017a; Santana and Fouad 2017). Yet, more is needed in terms of the implementation of self-care ‘on the ground’ – in clinical training programs and in the quality assurance processes of professional associations in the field of mental health.