A Case Study Exploration into the Benefits of Teaching Self-Care to School Psychology Graduate Students.

It has long been established that school psychology practitioners experience high levels of burnout. As a means of preventing burnout among future practitioners, school psychology training programs are frequently encouraged to teach and model self-care to students. This is particularly important as the current generation of graduate students experience high levels of anxiety and depression, but there have been very few examples in the research literature of how training programs should teach self-care and whether it is actually effective. The current study presents results from an exploratory case study, which integrated self-care instruction into graduate school psychology curriculum with a small sample (N = 22) of first-year school psychology students across two separate cohorts. Students created written plans with self-care strategies that they attempted to implement over the course of their first semester in graduate school. A qualitative review of their plans and written reflections revealed that students described many sources of stress upon entry into training, and most needed to revise their strategies for coping as stresses changed during the semester. Overall, student reflections revealed that the self-care activities were helpful to meet the demands of their graduate education. © California Association of School Psychologists 2020.

With the field of school psychology facing shortages in the near- and long-term future, the profession can ill afford to lose practitioners or prospective practitioners due to attrition. An estimated 5% of school psychologists leaves the field each year for reasons other than retirement (Castillo et al. 2014), a number that in most regions of the USA exceed the projected number of new school psychology graduates entering the field each year. While the exact number and reasons that school psychologists leave the field are unclear, one potential reason that has been proposed is the high level of susceptibility of practitioners to burnout. Research of school psychology practitioners (e.g., Wilczenski 1997; Kaplan and Wishner 1999; Mills and Huebner 1998; Huebner and Mills 1994; Worrell et al. 2006) has consistently found that while school psychologists have high levels of job satisfaction, they nevertheless also experience high levels of emotional exhaustion, feelings of depersonalization, and reduced sense of personal achievement, which unmitigated may result in burnout. Newman (2020) proposed that unaddressed burnout can lead to problems with professional competence and engagement in ethically questionable practices.

Application of self-care strategies has frequently been recommended as a means of preventing burnout and increasing meaning derived from work. In fact, engaging in self-care has been described as an ethical imperative by multiple authors (Lopez 2016; Barnett and Cooper 2009). Newman (2020) defined self-care behaviors as ones that are used to “establish and promote physical and emotional wellness, and to allay stress” (p. 179); self-care behaviors serve to both mitigate stress and promote personal wellness, thereby ensuring the optimal quality of services provided by practitioners. Self-care has been conceptualized as a multi-dimensional construct, with some authors proposing four domains (Newman) and others proposing six domains (Butler et al. 2019). Common elements of self-care definitions include behaviors designed to promote physical wellness (e.g., physical exercise and nutrition), enhance cognition (e.g., professional development, supervision), promote emotional well-being (e.g., seeking counseling, communication), and deriving meaning from work (e.g., mindfulness practices, religious and spiritual practices).

There is some correlational research regarding the effectiveness of self-care strategies on the functioning of mental health professionals. In a study of clinical psychologists, Stevanovic and Rupert (2004) found that psychologists who engaged in a greater number of self-care behaviors experienced greater job satisfaction. A survey of school psychologists (Bolnik and Brock 2005) found that 94% believed that engaging in self-care practices was important, and more frequent strategy use was associated with fewer physical symptoms of stress. Coster and Schwebel (1997) used a mixed methods approach to identify that 26% of psychologists had experienced personal impairment, and that effective strategies to address impairment included attending to personal relationships, going on vacations, striking a work-life balance, and developing self-awareness.

In summary, this research evidence seems to provide at least some support for the importance of school psychologists engaging in self-care behaviors. Based on these findings, researchers writing about self-care for psychologists frequently recommend that graduate programs directly teach self-care to prepare students to use self-care strategies in their future professional careers (Newman 2020; Huebner et al. 2002; Barnett et al. 2007; Barnett and Cooper 2009), but there is very little empirical research to guide these recommendations. There are a small number of studies that have examined self-care strategy use by graduate students in mental health professions. Myers et al. (2012) examined stress and self-care behaviors among clinical psychology graduate students and found that sleep hygiene, social support, and mindful awareness were related to lower stress levels. Turner et al. (2005), in a survey of school psychology interns, identified a number of strategies used by interns to manage stress including self-awareness activities, social activities, exerting control over professional activities, and appreciating intrinsic professional rewards, all of which were identified by the interns as being effective strategies. These studies provide some correlational evidence for the importance of self-care for graduate training, but the question of whether self-care behaviors can be successfully modified by training programs remains largely unexplored.

Several authors (Lopez 2017; Barton et al. 2019) have described various ways that school psychology training programs could integrate self-care into their curriculum, but there remains little evidence as to the effectiveness of these recommendations. Lewis and King (2019) described efforts to integrate a self-care unit into social work students’ field experiences, and provided qualitative evidence attesting to the benefits to students, providing a potential model for school psychology training programs to use.

It is particularly important to consider the self-care needs of graduate students in school psychology given the overall context of high mental health needs among graduate students in general. A recent study (Evans et al. 2018) found that graduate students both in the USA and internationally have six times the rate of depression and anxiety in comparison to the general population. There is some reason to believe that these rates may be higher in school psychology programs due to lower rates of financial support than other disciplines (Proctor and Truscott 2012) and the nature of school psychology training that involves intensive coursework and fieldwork (Barton et al. 2019). A study of training programs in school psychology (Gadke et al. 2018) found that in the 2016–2017 academic year, one student withdrew from their training program for every 9.1 graduates at the specialist level and for every 9.6 graduates at the doctoral level.

Based on this information, it seems reasonable to consider school psychology graduate students a population that is vulnerable to stress and anxiety, yet vital to the future health of the school psychology profession. Training programs need to develop a deep understanding of the sources of stress for graduate students in school psychology and a means by which to assist students in coping with these stressors. With self-care strategies having emerged as a promising practice in mitigating stress and burnout, training programs should seek to design ways to integrate self-care into their curriculum and monitor the effectiveness of doing so.

An important question to consider when attempting to train students to apply self-care strategies is an understanding of the nature of self-care. Much of the correlational research into self-care practices by mental health professionals has at times defined self-care as engagement in a number of coping behaviors at a specific point of time (e.g., Stevanovic and Rupert 2004; Bolnik and Brock 2005). This research tradition suggests that self-care might be best conceptualized by considering the volume and diversity of coping skills employed by individuals. On the other hand, the iM-PAACT framework (Brown 2019) defines self-care as a more fluid concept, comprised of four stages: (a) prioritizing self-care, setting goals, incorporating into schedule, (b) implementing self-care plan and refine as necessary, (c) connecting internally and with an external social support network, and (d) thrive by fully engaging in the self-care plan and regularly re-assessing and adjusting the plan as necessary. These same core elements are consistent with the self-care plans developed, implemented, and revised by graduate students in the current study. Moreover, drawing from the related literature on coping strategies for managing stress, coping skills have been theorized to fall within two distinct categories (i.e., problem-focused or emotion-focused; McNamara 2000). Using active problem-solving is an example of problem-focused coping. In general, such problem-focused coping is associated with better functioning and management of stress compared to emotion-focused coping. Arguably, proactively planning for self-care in the midst of school- and work-related stress can be considered a form of problem-focused coping. The theoretical orientation is important because trainers interested in incorporating self-care into school psychology curriculum may make different decisions about how and what to cover based on an understanding of the construct of self-care.

The present study was designed with two primary goals in mind. First, it is important for school psychology trainers to better understand the nature of the construct of self-care and how it can meet the needs of graduate student trainees. Second, it is important to understand whether an intervention aimed at self-care could be effective as a means of addressing stress experienced by trainees in graduate school. Therefore, this study was designed to provide an in depth understanding of the self-care practices of two cohorts of graduate students following a sustained semester-long intervention to integrate self-care into the school psychology training curriculum through a systematic case study inquiry. Case study research has a long history in many disciplines, and is especially appropriate in circumstances in which an in-depth description of a case may inform future theory, research, and practice (Creswell and Poth 2018). Case study research is particularly useful in situations in which the primary research questions involve understanding the how and why behind a construct and intervention, especially when conducted over a period of time (Yin 2018). In this study, an analytic approach called explanation building (Yin) was undertaken to provide a detailed examination of the experiences of the graduate students while experiencing a self-care intervention, intended to help other researchers and trainers conceptualize the fluid nature of self-care and whether an intervention based on the iM-PAACT model could improve self-care practices among graduate students.

Methods

Participants

Two separate cohorts of graduate students across 2 years (N = 22) enrolled in their first semester at a school psychology training program participated in the present study. Within each cohort, 100% of enrolled students participated in the self-care intervention in the present study and all completed the study through the three measurements. The school psychology program is a combined specialist level and doctoral level (Psy.D.) program and is located in a small private university in the northeastern USA. In the present study, 14 of the participants were members of the specialist program and the remaining 8 were enrolled in the doctoral program. All students participated in the intervention described in the present study as part of the required coursework for their field experience seminar. Per the university’s committee on ethical research with human subjects, all participants were given the option to exclude the use of their anonymized data for this project.

Due to the small sample size in the present study, detailed demographics on the participants could not be reported due to the risk of revealing their individual identities; however, statistics on the overall graduate program during the time the study was implemented are available to convey information about the characteristics from the population that the participants derived. As reported by Gadke et al. (2018), approximately 14 to 16% of school psychology graduate students nationwide are male, and approximately 27% are students of minority status. At the time of the study, the program overall had a percentage of students of minority status of 8%, which is lower than the national average cited above. The percentage of male students enrolled in the program overall was 16%, which is in line with the national average cited above. Because of the very small number of male and ethnic minority students who were participants in this study, in all responses, identifying information was masked to prevent revealing identities. In some cases, participant responses were altered slightly to remove or change information that could be identifiable, in order to mask their identities.

The two cohorts participating in the study were enrolled in consecutive academic years. The first cohort (n = 13) was larger than the second cohort (n = 9), but the group composition was overall similar. The large majority of students were in their early twenties and were enrolled in graduate school within a year of receiving their undergraduate degree; however, it is not possible to provide detailed age data due to risks to breaking participant confidentiality. Per Yin’s (2018) recommendations, case study research can provide support for the external validity of their claims through replication of its procedures; therefore, having two separate cohorts complete the self-care intervention, while the overall number of participants is small, helps to strengthen the validity of the conclusions.

Program Characteristics

The school psychology training program at which participants were located is housed within a college of graduate studies in counseling, psychology, and education. The school psychology’s specialist program is approved by the National Association of School Psychologists and the Psy.D. program is accredited by the American Psychological Association. At the time of data collection, there were 4 full-time faculty with primary appointments to the school psychology program.

The training program uses a cohort model with both specialist and doctoral students taking the same coursework in the first semester. Students are required to take a total of 18 credit hours in their first semester. The first semester within the training program emphasizes acquisition and maintenance of personal and professional skills. Therefore, students take foundational coursework in learning and cognition, psychometrics, individual norm-referenced assessment, interpersonal communication skills, cultural awareness, and perspectives in school psychology. In addition to coursework, students in the training program are required to enroll in a school-based practicum experience 1 day per week for a total of 90 h in the first semester. Finally, students also are assigned a graduate assistantship, which provides partial tuition remission in exchange for 5 h of work per week.

One unique characteristic of the training program is its location, which is in a rural community over an hour’s drive away from major population centers. This provides students with experiences in rural schools and populations, but does make it more difficult for students who are working full time to commute. Therefore, many of the students live in apartments in fairly close proximity to the university during the academic year.

Instructor Characteristics

The primary author served as the instructor for the field experience course and the facilitator for the self-care intervention. In this role, there was the advantage of being embedded within the system and milieu along with participants, as well as the drawback of potential lessened objectivity from serving in an evaluative role to the participants. The instructor was a white male in his late thirties, and was in his first 2 years as a full-time core faculty within the school psychology training program over the course of the intervention. Prior to joining the program faculty, the instructor had 12 years of experience as a practicing school psychologist, and drew heavily on these experiences in describing the importance of self-care throughout the intervention.

Procedures

Both cohorts participated in the self-care intervention in their first semester field experience seminar. The overall goal of the intervention was to help participants reach the thriving state of self-care based on the iM-PAACT model (Brown 2019) for application of self-care. The transactional model of coping emphasizes active application of coping in response to appraisals of stressful events (Lazarus and Folkman 1984), and intervention in coping skills emphasizes application of problem-focused strategies and reducing use of avoidance-focused strategies (McNamara 2000). The thriving state of self-care suggested by iM-PAACT model predicts that this coping approach can be developed through promoting the prioritization of self-care, developing and evaluating a plan, and connecting internally to self-care and externally to others (Brown 2019).

A summary of the steps of the self-care intervention designed to adapt the iM-PAACT (Brown 2019) framework is included in Table 1 for quick reference. During the first week’s seminar, participants were prepared for their practicum experience through discussions about expectations and requirements. The first step of the self-care intervention, a didactic discussion led by the instructor, was embedded into this initial seminar. This discussion began with a short lecture about the effects of stress on professionals in school psychology, and the progression of unhealthy stress that can lead to burnout and problems of professional competence, based on the models of stress proposed by Newman (2020) and McNamara (2000). Participants were prompted to propose and share potential sources of stresses in their lives that could potentially lead to this unhealthy progression. The instructor then described that problematic stress could therefore lead to professionals engaging in ineffective and unethical practices. Finally, the instructor introduced the notion that self-care strategies are posited to be a potential buffer against this negative progression.

Table 1

Key components of the self-care intervention

Step	Brief description
1. Didactics	In the first field experience seminar, students were introduced to the idea of self-care as a means to avoid burnout.
2. Guided self-study	Students were assigned to research self-care through a collection of articles and websites. Specific readings assigned included: • Self-care: the missing link in best practice – Part I (Lopez 2016) • Self-care: the missing link in best practice – Part II (Lopez 2017) • Developing a self-care plan (Reachout.com, n.d.) • Best practices in early career school psychology transitions (Silva et al. 2014) • Self-care starter kit (Butler and McClain-Meeder 2015)
3. Self-care plan design	Students were required to design their own self-care plan and submit it to the instructor prior to the second week of the semester.
4. Reflection and revision	At time 1 (1 week into the semester), time 2 (7 weeks), and time 3 (14 weeks), students completed written reflection about their sources of stress and how their self-care plan was working or was not working to help to manage these stressors.

Next, participants engaged in self-study with the goal of creating a plan with strategies that they could apply for self-care. Creation of a written plan to address stress through self-care that is revised over a period of time is consistent with theoretical models of self-care (Brown 2019) and parallels coping skill training as proposed by McNamara (2000). A series of readings and websites were provided to participants (see Table 1 for a list) to help them to generate ideas about how to structure and design a self-care plan. The participants were not given specific criteria for what format or content to include in their plans, but were advised to create plans that were multidimensional, individualized, specific, and realistic, so that the plan would reduce stress without adding new stress (Newman 2020; Lewis and King 2019).

Participants submitted their self-care plans and a reflective writing piece to the instructor prior to the second week of class. These responses were used to facilitate a group discussion in the following seminar session. Participants had the opportunity to share stressors and strategies they attempted to incorporate into the plans, which also helped to serve as member checks to ensure the credibility of the instructor’s interpretations of their written responses. During this discussion period, the instructor primarily engaged in reflective listening while encouraging participants to think about ways that they could ensure the effective implementation of their plans.

Participants’ self-care plans and written reflections were assigned a pass/fail grade based on completion of the requirements, which all participants did successfully. A brief written response was provided by the instructor to each participant, commenting on content in the student’s reflective writing and encouraging their use of self-care strategies. The following is an example of one of these feedback comments:Discussion about implementing self-care strategies was embedded throughout seminars over the next several weeks, which was integrated with discussions about their professional work behaviors, and the nature of school psychology service delivery. While participants were encouraged to adjust their self-care routines throughout the semester, they were formally asked to revise and reflect on their self-care plans at two points. Seven weeks into the semester (time 2), participants were required to submit an updated self-care plan and written reflection in which participants were asked to reflect upon how well their plans worked, and to describe how they adjusted their plans to better meet their needs. The instructor used their responses in the following seminar session to again facilitate a group discussion about stress and self-care. Finally, this process was repeated at the fourteenth week of the semester (time 3) as a means for participants to have a summative examination of their self-care and stresses in their first semester of graduate school. As before, their responses were used to lead a debriefing session in the last field experience seminar session for participants to reflect on the role of self-care in their graduate education and to plan for the future.

I’m glad to see the honesty in your response about feeling stressed. It’s important to recognize when your stress level goes up and down so that you can react accordingly. Don't be afraid to reach out to others, it’s not a sign of weakness! Good luck with following your self care plan this semester and managing your stress.

Data Sources

Qualitative data used for the study included the student’s self-care plans and written reflections submitted as part of the coursework requirements at three measurements: time 1, time 2, and time 3. Reflections and plans were both de-identified with student names and identifying characteristics removed from responses prior to analysis. As sources of data for this project, the written reflections were useful in understanding participants’ cognitive appraisals of stressors and their coping responses, making them amenable to interpretation based on the transactional model of coping (Lazarus and Folkman 1984).

Yin (2018) described tactics that can be used in case study research to support construct validity of conclusions. The first such tactic is through the use of multiple sources of information. While participant interviews and seminar discussions were not transcribed for separate analysis, they did provide external verification of the contents of the participants’ written reflections, helping to support that they represent an accurate account of their experiences. A second tactic described by Yin is establishing a clear chain of evidence for case study data. To analyze the written documents in this study, de-identified student reflections were initially downloaded from the online course management software. These raw responses were compiled into a single document in Microsoft Word. After compilation, participant responses were read by the primary author twice to identify excerpts of the response that could be relevant to understanding the responses of the participants based on the stages proposed by the iM-PAACT model (Brown 2019). These excerpts were then extracted into a separate research database in Microsoft Excel, thus providing a clear chain of evidence for the qualitative data to be analyzed.

Data Analysis

Once the participant response database was compiled, the analysis strategy for these data sources was developed based on recommendations for case study research by Yin (2018) and Creswell and Poth (2018). In general, a pattern matching approach was used to analyze the participant responses based on the iM-PAACT model (Brown 2019) and transactional model of coping (Lazarus and Folkman 1984; McNamara 2000). Yin described pattern matching as a technique in case study research involving searching for patterns in the data predicted by theory or prior research. A subset of this approach, explanation building, is particularly useful when attempting to understand how and why observed outcomes occur, based on a prior theoretical model. This approach was selected as the major goals included understanding how participants appraised and planned self-care strategies to cope, how participants adjusted these plans over the course of the semester, and how the participants evaluated the intervention and plan as being effective in helping them meet the stressors experienced during graduate school.

Based on Yin’s (2018) recommendations, the analysis of the qualitative data followed an iterative process. The authors started the process with a conceptual model for stress and self-care, specifically the transactional model of coping (Lazarus and Folkman 1984; McNamara 2000) and the iM-PAACT framework (Brown 2019). The analysis started at a broad level through an initial reading of all responses in the response database, followed by a closer reading at the element level within responses to examine for information that matched patterns predicted by theory and might yield the explanatory information needed to respond to the research questions. These responses were then developed into codes through which themes in responses could be identified, and as Yin recommended, these initial themes were then compared to the prediction based on the theoretical models. Finally, the explanations were again compared to the data, and the second cohort provided an opportunity to test these interpretive explanations with a new data source. Responses were found to match patterns that were extracted into three major themes upon which the findings section is organized.

Several efforts were undertaken to ensure the validity of these analysis procedures. First, and very important as identified by Yin (2018), the authors considered several alterative and rival interpretations at multiple stages of the analysis process. As one example of such an explanation, the authors were aware that participants could experience stressful life events outside of graduate school which could influence their implementation and selection of self-care activities; to help guard against this threat, all responses were examined for information about outside stressors that could potentially have affected the individual participants. Other rival explanations considered during the analysis phase are noted in the findings section.

Another strategy used to support the validity of the analysis was through triangulation of multiple information sources (Creswell and Poth 2018). Member checking to ensure credibility of the conclusions happened throughout the course of the semester through in-class discussions of the themes the instructor identified in participants’ responses. The instructor also debriefed with the participants as a group following the submission of final grades to help make sure their responses would be similar in theme to the written products used for analysis in the present study. Prolonged engagement with participants over the course of the academic semester helped the author to have a relationship that encouraged honest and candid responses, and is considered to be another good practice in qualitative research (Creswell & Poth).

The reliability and credibility of the explanations were supported in the research process through a memoing notetaking procedure to document contemporaneous process notes (Creswell and Poth 2018). A replication of the intervention and data analysis of the study with two separate cohorts gave an opportunity for initial explanations developed after the first year to be checked with new data in the second year of the study, and provided additional support for the findings (Yin 2018). Finally, while it must be noted that the primary author was the course instructor and therefore may have been prone to bias, being embedded with the participants over the course of a semester also helped to lend credibility to the analysis (Creswell & Poth).

Findings

Theme 1: an Appraisal of Stressors and Problem-Focused Coping Helped Participants to Prioritize Self-Care and Adopt a Problem-Focused Coping Strategy

The iM-PAACT model (Brown 2019) described the first stage of thriving with self-care to be prioritization of self-care. To support the prioritization of self-care, and participant development of problem-focused coping strategies (McNamara 2000), the self-care intervention began providing participants with didactics about self-care and stress, and requiring them to make an appraisal of their current stressors. A summary of stressors identified by participants at time 1 is presented in Table 2. As noted in the table, the majority of participants reported stress in relation to the rigors and difficulty of their graduate coursework, and their ability to stay organized and manage time to effectively meet these challenges. Many of the participants described the origin of this stress being internal, as exemplified by the following response from a male graduate student in his early twenties:By requiring participants to engage in this self-appraisal, the goal of the intervention was to help them prioritize self-care and develop plans to help them meet their needs, thus adopting a problem-focused coping strategy (McNamara 2000). Per the iM-PAACT model, “The goal at the prioritize stage is to identify a variety of activities that seem most likely to bring fulfillment and are realistic for the particular individual. Consideration for personal interests and resources is key” (Brown 2019, p. 41). That said, the research literature in self-care gives little guidance as to how professionals should organize, plan, and implement self-care strategies.

Table 2

Frequent sources of stress at time 1

Stressor	n (%) reporting	Sample quote
Graduate school—academics	14 (63.6%)	This program is intense and I have started to become overwhelmed. It is a lot of different assignments to keep track of. I get anxious about missing an assignment or reading. Although I am very excited to continue my studies, I have not quite found a rhythm yet.
Managing personal relationships	7 (31.8%)	I am also very stressed about maintain [sic] my relationships. I talk with my parents quite a bit and I have already talked to them less since I have been here, in comparison to past years. Also, I want to maintain a healthy relationship with my boyfriend. I’m nervous about making sure I balance my relationship and my studies.
Health	4 (18.2%)	Because I have had an unhealthy propensity to choose eating, drinking, smoking, and sleeping in my past, I know that this makes me feel horrible about myself, my capabilities, and what I am contributing to the people and things around me.
Finances	2 (9.1%)	Money can be a stressor for me -- doing things that donot cost money is good.
Distance from home	2 (9.1%)	My biggest life stressors include being far away from home and my long distance relationship.

The biggest stressors in my life are largely internal. They’re preconceived notions about what I should be doing, or what I should be able to do “on my own.” They’re also issues surrounding a consistent drive to “accomplish” as much as possible, to the detriment of my own health and well-being.

Through an analysis of participants’ self-care plans developed for time 1, it appears that the strategies that participants included in their initial plans largely mirrored the stressors they reported at the start of graduate school in primarily addressing academic and social-related sources of stress. All participants organized their strategies into several domains, which was recommended in some of the readings they completed as part of the assignment (e.g., Butler and McClain-Meeder 2015). A summary of the most common domains included by participants, and examples of strategies that they included under those domains, can be found in Table 3.

Table 3

Example self-care strategies included on participant self-care plans

Domain	Example strategies
Physical/body	Exercise on a regular basis (4–5 × week) Take a walk Posture adjustment Get at least 6 h of sleep per night
Mind/mental	Allow for internet and video game breaks Engage in ‘brain breaks’: reading novel, doodling Maintain realistic goals and expectations regarding school and grades Break down large tasks into small tasks
Social/relationships	Spend time doing something active with <significant other> on weekend Spend 1 day a week with cohort friends (no school work, actual fun) Schedule facetime with partner
Emotional	Make note of daily gratitude CRY and deep breath Listen to music to calm down/ release whatever you are feeling Write for fun
Spiritual	Spend weekends in nature Practice mindful positivity: look for the best in a situation Sing during class breaks Go to church (Sundays) or read several Bible verses
Work/professional	Schedule breaks to avoid burnout (90-min on, 10-min off, etc.) Ask cohort members for advice Make lists and stick to them with due dates Celebrate task accomplishment

Spend time doing something active with on weekend

As noted, it appears that participants developed plans that were tailored to their individual needs based on their self-appraisal of stressors. All participants included strategies that were intended to support their ability to keep up with coursework and manage their time. All participants included a domain for physical health that initially included some kind of strategy related to physical activity or exercise, ranging from planning on visiting the gym 5 days a week for exercise to going for a walk regularly. A large majority of participants (n = 17; 77.3%) included spending time with a significant other (defined in the study as spouse, partner, girlfriend, boyfriend, fiancé) as part of their self-care plan. Consistent with previous research with self-care (Lewis and King 2019), the majority of participants (n = 20, 90.1%) included a spiritual health domain, which included a large number (n = 9; 40.9%) who indicated that religious expression, including prayer or attending religious observances, was an important part of their self-care.

As noted, it was important to the study’s analytic procedures to search for information that did not fit predicted patterns. To mitigate the effects of a history threat on interpretations, the authors considered it important to note when participants described unusual discrete events that could impact their stress and coping response. Three participants did report outside events which were coded to be in this category, for example, the death of a loved one and a serious health issue. Responses for these participants were flagged and efforts were made to analyze their descriptions of stressors and coping separately, so as to avoid drawing conclusions about the idiosyncratic responses to these events. It is important, however, for trainers to note the potential impact of similar events on the stress and coping of graduate trainees. Finally, one theme present in the responses of social work trainees in previous self-care research (Lewis and King 2019) was that of compassion fatigue and secondary trauma due to stressful situations at their field placement. While these themes were expected in the present study, they did not feature in participant responses outside of two participants. The authors interpreted this finding as being related to the typical activities at the field placements in the first semester of the training program, which primarily involve shadowing, observing, and assessment, as opposed to providing mental health counseling.

Theme 2: the Intervention Procedures Facilitated Participant Engagement in a Cycle of Acting and Adjusting Their Plans

The intervention procedures included several features which were designed to support participants’ implementation of self-care strategies, assess their plan, connect with self-care both internally and externally, and adjust their plans accordingly. These included the cycles of reflections and revisions at time 2 and time 3 and the group discussions about self-care in the seminar. The iM-PAACT model (Brown 2019) predicts that these processes are important to successful application of self-care in response to constantly shifting sources of stress.

Participants were asked at time 2 and time 3 to re-evaluate their sources of stress to provide an insight into their shifting appraisals of stress. The most prominent theme in participant responses regarding the evolution of their stresses was the need to find a balance between academic demands and other activities. There was a wide variance of responses to how participants evaluated their success at finding this balance at time 2 and time 3, with participants describing the semester overall as causing very little stress and some conveying that they experienced extreme stressors.

Consistent with other work on self-care that has followed individuals over a length of time (e.g., Lewis and King 2019), self-care practices for participants in this study evolved over the course of the semester in response to their shifting appraisals of stress, with participants experiencing some successes and challenges implementing strategies that they initially thought would be successful. All participants made adjustments to their plans at time 2, and all but two made further adjustments at time 3. A summary of the most common adjustments to plans can be found in Table 4. As noted, most participants experienced difficulties in time management as a primary barrier for regular application of self-care strategies. Many participants reported that they initially under-estimated the time that coursework, practica, and other responsibilities related to graduate school would take. One student, who had written at the start of the semester that graduate school had already threatened to become overwhelming, commented at the end of the semester, “I quickly realized that those stressors from undergrad and the ways I would cope with them, were not going to help this year.”

Table 4

Most frequent adjustments to plans attime 2 and 3

Adjustment	n (%) reporting	Sample quote
Altering the planned frequency or duration of strategy	14 (63.6%)	With the assignments piling up, I was unable to make it to the gym three times a week like I wanted, and I was unable to create a time-management plan and try to stick to it.
Increase in time management strategies	7 (31.8%)	When I initially wrote the self-care plan, I had no idea what kind of stress I would face with graduate level courses. Although I knew that graduate school would require a lot of attention and dedication, I had never experienced such academic rigor and did not understand the importance of a self-care plan.
Seek mental health support	4 (18.2%)	There are some things I have never felt comfortable telling other people and I have held certain things in. Talking about my anxieties has helped just because I told someone. It was a big weight off of my shoulders that has let me be happier and more focused on school.
Decrease in spiritual strategy use	2 (9.1%)	On the other hand, the spiritual section of my original plan has been hard for me to do this year. It has actually created more stress for me because I have been trying too hard to make it work when it is not going to. I spent more time stressing about how to fit it in than on using it to relieve my stress.

As noted in Table 4, there were some participants for whom the cycle of revision and reflection on self-care plans provided impetus to seek out counseling support. All of these participants described the change as being very positive; for example, one female graduate student in her early twenties wrote on the benefits of seeking counseling: “I am so glad I started following this assignment because I have never felt so mentally healthy and fit in my entire life. I feel like a whole new person this semester because I am prioritizing my mental and physical health.”

One domain of self-care that participants found particularly difficult to implement was in the area of spiritual health. One-third of participants who originally included strategies regarding religious expression removed these strategies when revising their plan. This finding was an interesting difference from results reported in other research (Lewis and King 2019), but overall is consistent with the iM-PAACT model in terms of participants developing a plan that is adapted to their needs.

Theme 3: Participants Perceived that the Intervention Procedures Supported Their Thriving with Self-Care

Brown (2019) proposed that the final stage in the implementation of self-care based on the iM-PAACT model is characterized by thriving. Reaching this stage does not mean that a professional’s self-care plan is a finished product, but rather that the professional has fully engaged in a plan for self-care which is continually re-assessed and adjusted to meet changing needs. Individuals at the thriving stage will have prioritized their well-being as a fundamental aspect of their professional effectiveness. In the present study, evidence that participants were in the thriving stage was evaluated through how they described their reactions to their self-care plan and their descriptions of their approach to self-care as part of their professional functioning following the semester-long intervention. Importantly, a participant who is thriving could still struggle with implementing certain aspects of her plan, as long as self-care was clearly described as a priority and she provided evidence of committing to a continual cycle of assessment and adjustment of a self-care plan. Based on the model, all participants in the study were characterized as being at least partially in the thriving stage of self-care at the end of the intervention. Due to the richness of their responses, excerpts from three student reflections are presented below, which represented the continuum of responses to these questions (Yin 2018).

The first such response, from a female participant, demonstrated the importance, predicted by the iM-PAACT model (Brown 2019), of prioritizing self-care, and adjusting self-care behaviors to provide a balance of thriving in a way that enhanced productivity. The participant also described a commitment to continuing these practices in her graduate school and professional career, an important mark of thriving:The second illustrative excerpt, from a male participant, exemplified how participants described the role of self-care as fundamental to their future professional functioning:Finally, the reflection from the following female participant spoke to the difficulty in developing an initial plan that was adequate to meeting the demands of graduate school. She disclosed that the beginning of graduate school was a very difficult personal and academic transition, which caused her to feel unsure if it was the right match for her goals. The ambivalence regarding the effectiveness of her self-care plan was evident in her response, although it does seem clear that while the plan itself may not have solved all of her stresses, she nevertheless saw the importance of dealing with stress to be effective in her academic functioning.While rival explanations were actively considered in making interpretations of thriving in participant responses, such as whether some outside influence rather than the intervention procedures might have led participants to make these statements, it is important to point out that the design of the research made it impossible to rule out some alternate explanations for the results. One example is that of a maturation threat; in other words, that the experiences of the participants could simply be explained by normal changes that would have occurred over the first semester in graduate school even in absence of any intervention related to self-care. While some participants described outside stressful events or mitigating factors in implementation of their plans, all nevertheless attributed their commitment to self-care at least in part to the semester-long intervention.

Overall, I think that having a self-care plan has been helpful this semester. If I had not thought about doing activities that I enjoy or that help me to relax, I think my only focus would have been school work. I am glad that through this assignment I was able to be reminded about the importance of taking time for myself and doing activities that I enjoy. I also think that while implementing my self-care plan took time away from completing school work, having that break made me more productive once I started school work again. I think that continuing to implement my self-care plan will be helpful as I continue through graduate school and begin working as a school psychologist.

I imagine that any professional career I choose will come with assorted ethical dilemmas and stress-inducing deadlines. Such troubles must not only be met with adequate clinical expertise, but an effective self-care regimen. I imagine that as I become more familiar with the program, and how best to formulate a self-care plan, I will be extremely prepared for these situations… My experiences will self-care throughout this semester, and the forthcoming, will be influential in shaping the professional I become. I fully expect proper self-care to become the foundation on which I build my future career.

My self-care plan did not address the stresses that come with graduate classes and field experience. For the initial creation of my self-care plan, I put things in that I have done before that have helped me relax and unwind from stressful days. I quickly learned that the stress I used to have; did not compare to the stress I was experiencing this semester. I did not plan my self-care very well when I first started it. When beginning the semester, I was not aware of how much stress and how little time I would have on my hands. This was a big transition for me. In a way, my care plan helped me through those moments of stress but they did not help me in the long run when I first made it because I really had no idea what to expect throughout the semester and it has been a large transition which made me tweak my self-care plan.

Discussion

Despite the focus in the field of school psychology in attracting and retaining professionals to meet the personnel shortage, and the long-recognized risks of burnout in the profession (e.g., Huebner & Mills, 1994), there is little research on the application of self-care strategies as a means to prevent burnout and attrition. This is especially important for training programs, who obviously play a large role in developing new school psychology professionals to address personnel shortages. While there are many scholars (e.g., Newman 2020; Huebner et al. 2002; Barnett et al. 2007; Barnett and Cooper 2009) who have recommended that training programs include self-care in their curriculum, most of the existing research into self-care is correlational, and therefore, it is unknown how training programs should best accomplish this among many other priorities, and whether interventions to teach self-care are effective.

The present study attempted to address this shortage in the literature by developing an intervention for self-care that was implemented over the course of the semester and documenting outcomes of the intervention. As a case study example of a self-care intervention, this study is intended to guide the development of future research, as a proof of concept that a self-care intervention developed based on the iM-PAACT model and the transactional model of coping (Lazarus and Folkman 1984; McNamara 2000) can be feasibly integrated into school psychology training. All participants who participated in this self-care intervention considered the creation of a self-care plan in the context of their field experience class, with check-ins to monitor and adjust the plan, to be a helpful exercise. Several participants were quite enthusiastic, reporting that the stressors they experienced in graduate school were much more intense than anticipated. Consistent with research documenting high levels of stress and anxiety among graduate students (Evans et al. 2018), participants in the present study described many and varied stressors at the start of their graduate education. The largest source of stress was graduate training itself, with students worrying about being able to manage the volume and difficulty of the material. Students also frequently expressed anxiety regarding managing their personal and family relationships amid the demands on their time caused by coursework.

Students participating in this study designed self-care plans that appeared to be geared to meet the stresses they anticipated; however, many of the students found their initial plans to be inadequate to meet the demands of the training program. The iM-PAACT model (Brown 2019) described application of self-care to be a process that best results in a plan that is individualized, continually assessed, and adjusted to changing stressors. Previous research with self-care for students in mental health training programs (Lewis and King 2019) also documented that self-care strategies for students evolved over the course of the semester and needed to be monitored and revised to be effective. There was evidence that the intervention procedures helped to support these behaviors among participants; future research should further explore the process of adopting and sustaining self-care behaviors, to inform efforts at instructing students and practitioners to engage in these behaviors.

While the present study described a case study which should suggest several important hypotheses for future research to consider, there are some important limitations in the design of the study that must be taken into account in interpreting the results. First, the study’s goal was to obtain an in-depth understanding of the stresses that school psychology trainees face and the strategies they use to cope with those stressors after a self-care intervention. As a result, the participants were all enrolled in a single graduate program, and were overall a more homogenous group in comparison to school psychology graduate students overall. This may be particularly important if considering applying the conclusions of this study to students who are members of a minority group. Proctor and Truscott (2012) for example found that themes of fitting in with other cohort members as being a paramount concern to students of minority status, but in the present study among largely white European American students this theme was much less prominent. Future research should therefore consider using a larger and more heterogeneous sample to understand how the study’s conclusions might extrapolate to students of minority status.

The second important limitation was the lack of a comparison group to determine whether any described findings are causally related to the self-care intervention. Without a control group, the design of this case study was such that it could not rule out whether, for example, the experiences described by students might simply represent normal maturation in response to starting a graduate program. Finally, an important limitation for the present study was in nature of the measures used for data collection and analysis. While efforts were taken to ensure the dependability and credibility of the data and conclusions, students were submitting the artifacts for a grade in their course, and may have been incentivized to exaggerate the importance or value of the self-care plan. Likewise, there were no external measures to estimate how often students were actually implementing strategies as they described in their reflections, nor any quantitative measures of stress and burnout.

Despite these limitations, the present study should provide researchers with a proof of concept model for embedding self-care into school psychology training. Given the research into graduate student mental health (e.g., Evans, 2018) and especially when considering the COVID-19 pandemic, for which there have already been documented negative effects on mental health in general (Gao et al. 2020), it is important to consider the mental health needs of students enrolled in school psychology training programs. Furthermore, it is an important professional outcome of training for students to develop coping mechanisms while in training. It is vital for future research to extend the understanding of the construct of self-care and explore interventions that can help inform practice and training recommendations.