The Evolution of Self-Care: From Explicit Techniques to Implicit Awareness

Aaron Farrelly and Dr. Louise Hopper

self care

Abstract

Background: Research focusing on self-care has typically examined the effectiveness of specific interventions within unique samples. This has culminated in a dearth of exploratory research surrounding the area of stress and self-care. Coupled with this, a lack of investigation within an Irish clinical population was apparent. The current study aimed to address the exploratory gap via investigation of the experience of stress from the clinician’s perspective, focusing also on self-care within this sample.

Method: Semi-structured interviews were conducted with seven Clinical Psychologists (3 males and 4 females) currently practicing in Ireland. Data was analysed via Inductive Thematic Analysis.

Results: A superordinate theme of Clinician Awareness emerged. This describes the awareness necessary on the clinician’s part to initiate healthy behaviour conducive to safe long-term practice. Analysis also identified three sub-themes; Physicality, Relationships and Work/Life Balance.

Conclusion: Findings of this research point towards the evolving nature of self-care within the sample of clinical psychologists. More than just techniques, clinician awareness adds a novel layer to self-care research and provides new scope for future research in this area.

Introduction

There is a dearth of research investigating the meaning of self-care to practitioners. To date, the focus has been on the specific effects of stress mitigation interventions.1, 2 Research lacks an in-depth understanding of the impact of stress and the need for self-care from the perspective of the caring professional.

Compassion fatigue has been conceptualised as a general ‘cost to caring’.3 Much research has considered how to ameliorate this cost to caring and emphasised self-care. This is the process of a practitioner caring for their own physical and mental health via different techniques in their own time.2 Research on the meaning of self-care to clinical psychologists is necessary to guide future interventions.

‘Cost to caring’ broadly examines the effects of stress for practitioners and various concepts have emerged demonstrating the nuanced manifestations this cost can take. Secondary Traumatic Stress is a condition that mimics Post-Traumatic-Stress-Disorder (PTSD) and develops through the indirect transmission of traumatic material in a clinical encounter.4 Conversely, compassion fatigue is a non-clinical term describing the cost of caring for traumatised individuals.3 Vicarious traumatisation details the transformation of therapists’ cognitive schemas related to identity, spirituality and worldview resulting from chronic exposure to clients’ trauma.5 Finally, ‘burnout’ is conceptualised as a state of physical, emotional and mental exhaustion caused by long-term involvement in emotionally demanding situations, rather than exposure to the trauma and suffering of a specific client.6

Experiencing the ‘costs of caring’ can result in increased depression and anxiety7, decreased job satisfaction8, reduced self-esteem9, disrupted personal relationships10 and loneliness.11 ‘Costs of caring’ also affects professional effectiveness, but more specifically this is due to effects on attention, concentration and the therapeutic relationship.12 These outcomes may demonstrate the damaging influence of unchecked compassion fatigue on the clinician.

It was determined that there was a dearth of research evaluating approaches to stress reduction in clinical psychologists.13 Although this realisation has been a catalyst for research on self-care interventions,14 the associated studies have focused exclusively on the effectiveness of self-care interventions and approaches, to the detriment of gaining a contextual understanding of stressors and self-care techniques. As a result, existing research illustrates the multiple manifestations of the impact of stress, but our understanding of self-care is left wanting in comparison.

Research has presented a four-factor model of self-care that includes intrapersonal, interpersonal, professional and physical domains.15 This model was further built upon by including a category dedicated to maintaining balance in the clinician’s life; a key sentiment throughout the literature in this field.16 Proceeding from this need for balance, researchers concluded that more holistic approaches to the mitigation of stress via self-care were necessary, and that these should incorporate a seven-day awareness to caring for self.17,18With this emerging factor of awareness held as a key aspect of self-care, further research has proposed that this awareness is essentially knowledge of the self.19 Others suggest that awareness is knowledge of one’s thoughts, emotions and behaviours. Therefore, it can be considered a state.20

Similar to this awareness, mindfulness has been consistently defined as maintaining awareness of oneself and one’s environment.21 Although research has identified subtle differences between mindfulness and self-awareness, these factors have also been found to be significantly positively correlated.23 This awareness also ties into spiritual self-care; an outlook of self-care incorporating the importance of balance and awareness in a clinician’s life.23 However, these various conceptions of self-care are limited due to a lack of exploration. The literature lacks the ability to contextualise reported stress and self-care approaches within professionals’ overall lived experience.24 As a result, there is a need for more research investigating the context in which self-care exists.

Such research represents an important step in bridging the exploratory gap between understanding why clinicians need to self-care, and what this act looks like from the clinician’s point of view. As proposed by Maslach & Leiter,25 the power of this research and its approach rests on the fact that it will essentially function as an organisational check-up, which is needed considering the nature of the job and the risks professionals are vulnerable to simply as a result of carrying out their role. Consider for example, 73% of qualified clinical psychologists in the USA reported clinically significant levels of stress. Similar levels of stress have been found among clinical psychologists in the UK.26 A lack of support for self-care in mental health workers has been proposed.27 It was concluded that a primary challenge for psychology was to build a more robust knowledge base regarding stress and burnout.28

The current study explores the meaning of self-care in a previously unexplored sample of Irish Clinical Psychologists. This research will examine daily stressors experienced and provide an exploration of self-care from the perspective of clinicians. Findings will inform future research on stress and self-care in this population.

Method

Design

A qualitative approach took place by means of semi-structured one-to-one interviews. This methodology was chosen as it has been demonstrated as most appropriate for research concerned with the meaning of phenomena as experienced by individuals.29 Semi-structured interviews were conducted using prompts to structure the interview and to reduce investigator influence.30 The resulting data was analysed using Inductive Thematic Analysis (ITA).31 Ethical approval was obtained from the Research Ethics Committee (REC) in Dublin City University prior to initiating data collection.

Participants

Purposive sampling was used to recruit seven clinical psychologists. The minimum qualification held by each participant was at Doctorate level. The average age of the sample was 42 years (SD =13.60). Hours spent practicing per-week (M = 37; SD =10.55) and average caseload per-week (M = 17; SD = 7.00) varied between participants. All participants were Irish clinical psychologists currently operating within multidisciplinary teams.

Data Collection

Upon demonstration of interest, potential participants were informed about the study. All participants then provided informed consent. Subsequently, a face-to-face interview was arranged in the clinician’s place of work. A total of seven interviews were conducted in different clinical settings around Ireland. The interviews lasted from 30 to 48 minutes (M = 31mins, SD = 17mins). All interviews followed the semi-structured interview schedule. Interviews were audio-record and transcribed verbatim by the researcher. This transcription including non-verbal sounds such as laughter, which added to the depth of information obtained.32 Post transcription, participants were emailed a copy of their transcript to review. Once conformation was obtained that each transcript was an accurate reflection of the participant’s experience, data analysis began.

Data Analysis

An inductive thematic key was created to organise ITA31 which incorporated various phases.33 The initial phase included familiarisation with the data via transcribing all interviews verbatim. Phase 2 was focused on the generation of initial codes from interview transcripts. In phase 3, initial codes were reduced into more manageable code extracts via the grouping of similar codes. In phase 4 new codes were collated with interview data and subsequent analyses of emerging themes was also conducted. The final phase hinged on defining and naming each theme – capturing the aspect of the data corpus that it represented. These themes and associated sub-themes represented the results of the thematic analysis.

Results

Thematic analysis of interview data revealed three themes; Physicality, Relationships and Work/Life Balance. These aforementioned themes formed the super-ordinate theme of ‘Clinician Awareness’. Clinician awareness aids clinicians by alerting them to stressors and the need to care for their own physical and mental health.

Clinician Awareness – The pre-condition for optimum self-care

More than any specific technique, self-care emerged as an overarching awareness of specific needs that were central to the maintenance of physical and mental health. “Clinician awareness” encapsulates this emergent principle of self-care. It can be described as maintaining awareness of one’s emotional and physical needs while conducting oneself as a clinical psychologist. Participants felt that this awareness could be utilised to foster positive self-care habits.

Physicality – The importance of body awareness in clinicians

Clinicians consistently reported self-care in terms of physical techniques and these were seen to have a consistently cathartic effect.

spending time doing things physically, because I find so much of our work is sedentary, that it’s, it’s like a total contrast to even be like, mowing the lawn, going to the gym”. [P1]

Meditation, mindfulness, yoga, daily swimming in the sea, cooling off in cold water, exercise. [P2]

Physical actions were mentioned by all participants as well as “grounding techniques” and hobbies such as reading. An awareness of the sedentary nature of a clinician’s job meant it must be balanced with adequate physicality. However, some clinicians may lose this awareness of the importance due to the demands of their post.

when I was in college I used to sing, and I stopped it, bad decision, because singing was great self-care for me and helped with stress”. [P4]

This dropping off of a physical outlet due to work demands is one example of how a lack of awareness can impede self-care. Clinical awareness arose from the understanding of how everything the clinician did affected them in some way.

I noticed that if I drop some of those things, that’s when I notice”. [P6]

Balance & Boundaries – Awareness as a bulwark to stressful potentialities

An awareness of the work/life divide was very important to all participants.

it’s just really important to make sure other aspects of your life aren’t put on hold” [P5]

scheduling in that balance, that balance with self, balance in lots of areas” [P7]

Clinician awareness did not just have ramifications for work-life balance; participants suggested that it radiated into many aspects of their job. A lack of awareness meant increased potential for the accumulation of stressors.

If we’re not checking in with that (stress), and we don’t have that self-awareness, we’re in big trouble. Because we don’t know what’s going well for us and we don’t know how to make sure that stays, and then we don’t know what isn’t going well for us, and how we can reduce that”. [P1]

Awareness was considered a pre-requisite for superior performance as a clinician. It was not considered an in-the-moment fix, but a tool to guide clinicians on the right overarching trajectory of self-care.

It’s about checking in, seeing what stresses you, and staying checked in with that, and how that changes over time”. [P1]

Being self-aware enabled one participant to pursue work in an area suited to their personality, thus reducing stress.

well it’s good that you learn either way, you either learn you hate it, or you learn that that’s where you want to go, trying to find a job that has the least emotional stress associated with it”. [P4]

Participants described self-care as active awareness; the ability to pragmatically analyse their situation and to not only mitigate stress in the moment, but to change their ongoing actions in order to function better. Finding their voice and creating healthy boundaries was key to this.

I was quite newly qualified still, and wasn’t as able as I am now to manage boundaries with what I was expected to do, whereas I’ve learned to have realistic expectations and to be able to say no to managers”. [P5]

Relationships – How awareness sculpts a safety network

Situated within the personal and work life of the clinician, relationships emerged as a potent avenue for self-care.

A lot of it is about spending time with my family, spending time with friends”. [P1]

it would be very hard, to be, doing this kind of work if you didn’t have friends and family”. [P2]

These statements show the importance of keeping up relationships and socialising when it comes to sustaining practice for clinicians. An important aspect of this self-care mechanism is the escapism provided by the contrasting nature of relationships.

none of my friends or family are in psychology, so actually its lovely, like going out, brunch, dinner, you know, its brilliant, because it’s never about psychology”. [P3]

Many participants spoke of the restoring and redemptive side to nurturing relationships.

taking some time in the evening to do something that restores you, that’s socialising for me”. [P4]

nurturing the important relationships in your life, and, the important emphasis on how they’re a two-way street, you’ve got to put into those people you care about in order to get it back, making sure you have time for them”. [P7]

Relationships were described as providing a safety network for the clinician, allowing their stress load to be either shared with colleagues, or forgotten with friends. Awareness allows the clinician to realise this importance of relationships and the role they play in not just escaping for a while, but actively benefitting practice via colleague alliances.

“I used to organise a monthly lunch with colleagues in the building…to keep connected in life”. [P7]

This simple act had sustaining and redeeming effects resulting from this particular clinician understanding the positive effects of work relationships. Awareness of the benefits of relationships was imperative to clinician health for all participants, not just for personal and work life. Awareness of the nurturing qualities of relationships also emerged from the importance of personal therapy for the clinician. Personal therapy was described as “vital” for practicing clinicians and it was seen as both a vehicle to achieve increased clinician awareness, and also as a relationship that takes an initial level of awareness to form.

the idea that was the greatest help was individual therapy, I knew what it was like to be a patient, I think that was the most helpful, it gave me insight, insight into my own blind-spots, my own limitations”. [P2]

This insight was intrinsic to awareness and provided the clinician with a more wholesome view of themselves. One of the most experienced participants suggested when speaking of trainee’s that:

they should all do a certain amount of personal therapy – of a psychodynamic nature, they need to understand their own defences, their own blind-spots, their own weaknesses”. [P2]

A number of this participant’s students had not carried out their own personal therapy. One participant felt it was an extreme oversight, or in other words a lack of awareness to not foster the important relationship of personal therapy.

I think people should practice what they preach, you see there are a lot of people doing this kind of work who really still have a lot of unresolved baggage”. [P2]

This participant felt that unresolved conflicts caused clients to remind clinicians of their own shortcomings, thus causing anxiety. The exploration as a result of initial awareness on behalf of the clinician to seek out personal therapy ultimately allows the clinician to develop greater awareness of themselves.

Discussion

This research investigated qualitatively the stressors faced and techniques used for their mitigation in a sample of clinical psychologists working in Ireland. The findings support the view that there is a significant amount of stress involved with carrying out the role of clinical psychologist. The primary finding in this instance was understanding the emergent principle of clinician awareness. It was found that clinician awareness provides a foundation for subsequent actions aimed at stress mitigation.

Self-awareness involves obtaining knowledge relating to markers of the self, such as emotions and triggers, via reflection. This reflection then allows a person to act more in accordance with their inherent values at a future time-point.19 In line with findings presented here and in previous research, there must be an attempt made to achieve a ‘seven-day awareness’ in clinicians.17 From the data, it was demonstrated that actions involving physicality, relationships and work-life balance could be described as stemming from an awareness on the clinician’s part that appeared as the pre-cursor to subsequent positive action.

Physicality

Participants spoke about the broad importance of physicality and its role in self-care. More specifically, exercise was a form of physical self-care. Previous research has demonstrated the psychological impact of exercise in other populations. Aerobic exercise has been associated with positive clinical outcomes for those with anxiety disorders.34 Six 20-minute aerobic exercise sessions over two weeks has been shown to alleviate symptoms in those with PTSD, Generalised Anxiety Disorder and Depression.34

One study has suggested that the anxiolytic effects of exercise are a result of the distraction from stressors while the exercise is being carried out.35 This may help to explain why participants cited exercise and physicality as important to self-care. These findings support the argument that exercise is an excellent self-care tool due to its efficacy and ease of implementation.34

Some participants ceased their physical outlets due to work demands, thus losing their beneficial effects. This cessation resulted in increased stress for the clinician. Self-awareness has been significantly associated with recognising the importance of self-care;22 if exercise had to be stopped due to a busy schedule, a clinician with higher self-awareness may have attempted to find a less time-consuming substitute to exercise, rather than just completely lose out on self-care.

Relationships

Relationships in the workplace have been directly linked to occupational stress and burnout.36 Evidence from this study supports the important function of relationships and how they can act as a safety net for each individual clinician. There is evidence that supervisors are important in helping to decrease stress37, this finding lending credence to the importance of relationships. With relationships being so important to clinicians, it could be demonstrated that awareness of this, and active work on behalf of clinicians to form alliances inside and outside of work is an active form of self-care. Work related sources of social support can take the form of supervisors or co-workers, whereas non work-related sources can take the form of family and friends.38 The onus is on the clinician to have the awareness to know of the important role of relationships in practice and then use this to actively sculpt a safety network. With the current pandemic actively limiting a clinician’s physical network and thus safety net, research should aim to investigate how clinicians dealt with this extraordinary change in events.

Relationships may also become stressed if not managed correctly. Low social support at work has been linked with helping professionals’ intentions to leave their profession,39 and sometimes relationships at work can cause stress due to the existence of power hierarchies within organisations.40  Overall, relationships can have a positive outcome on health and well-being, ultimately helping workers deal with occupational stress.41 Findings point to the importance of being aware of how relationships mediate stress; another potential avenue for future research on self-care.

Work-Life Balance

Another critical component of self-care was the development of a sustainable work-life balance23 which emerged as imperative to participants in this study. While clinicians may perceive their professional and personal lives as separate, self-awareness is needed to ensure healthy boundaries exist between these two aspects of life.42 This conclusion is key in the realisation of the significance of clinician awareness and the role it plays in practitioner well-being.

Greater awareness from the clinician can aid in the promotion of a healthier work-life balance. This plays into previously mentioned activities. Essentially, with more awareness a clinician can build a work-life balance that allows the actualization of both personal and professional aspirations. Focus on this work-life balance is another novel route for future research.

Strengths & Limitations

Findings should be interpreted in light of specific strengths and limitations of this research. Research concerning the experiences of clinical psychologists in Ireland in relation to stress and self-care is limited. This research has therefore provided an initial investigation of their experiences using qualitative methodology.

This study has a number of limitations. Semi-structured interviews were used to provide a framework for the discussion. This structure was mostly beneficial, but some participants limited their answers strictly to the questions rather than elaborate on their broader experience. Therefore, investigator influence30 may have played a part via the construction of prompt questions used with all participants. Future research should establish a less structured approach to the interview. It would also be helpful to include an additional step in which the interview schedule could be piloted, which was not possible in this instance due to time constraints. The transferability of the findings to other applied psychology roles is limited due to the homogeneity of the sample in this instance. It would be beneficial for future research to focus on other applied disciplines within psychology to begin elucidating consistent factors relating to self-care across populations.

Conclusion

The current research provided an initial understanding of the stressors and self-care techniques employed by Irish Clinical Psychologists. The elucidation and construction of the role clinical awareness plays in Irish clinical psychology is an important step towards enhancing self-care within the profession.14 Clinicians are aware that they are at risk due to the stressors inherent in their job (costs), and of the need for self-care, but self-care does not appear to be embedded in their role to the extent it should in light of ethical considerations. Self-care should not just be a ‘tick the box’ exercise. There is still much progress to be made before a holistic approach to caring for the self can be achieved.24

However, the literature23 and research presented here provides some initial steps towards a new understanding of self-care embedded in an awareness that acts as the pre-cursor to relevant and positive action. The findings of this research imply that the evolution of self-care from explicit techniques to implicit awareness is not to the detriment of any techniques. Rather, the awareness seems to complement the usage of techniques. Future research can investigate this process in more detail, such as whether clinical training influences a clinician’s outlook on self-care or whether it is an inherent attribute of some people to seek out healing activities more than others. There is a need to question clinician supports and education surrounding self-care so that we can consistently supply clinicians with the tools and knowledge to keep themselves both physically and mentally well.

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Authors

Aaron Farrelly, Researcher, School of Psychology, Dublin City University

Dr. Louise Hopper, Assistant Professor, School of Psychology, Dublin City University