Selflessly Selfish: Barriers and Recommendations for Self-Care

by Tyler McFayden, M.S., Virginia Tech 

The day to day of a graduate student is, overall, markedly selfless– we care for our lab, conduct work for our mentor, provide mentorship to undergraduate students, counsel our cohort, and primarily provide clinical services to those in need in our communities. Graduate studies are full of pressures to succeed, academic challenges, heavy workload, long hours, exhaustion, constant evaluations, and especially for clinical psychologists in training, it also entails emotionally-exhausting clinical training. Clinical psychology graduate students, in particular, experience high levels of stress that affect their overall mental health. In a large, national sample of psychology graduate students, over 70% reported at least one major stressor that interfered with optimal overall functioning (El-Ghoroury et al., 2012). Approximately 35% of graduate students in the US reported clinical levels of both anxiety and depression (Rummell, 2015), which is significantly higher than that of the general population (Kessler et al., 2003). These high stress situations result in physical ailments (e.g., headaches, neck pain) that occur in psychology trainees over double that in general populations (Rummell, 2015). Taking time for yourself can feel selfish, especially in the world of selflessly providing to others. However, in clinical settings, self-care, defined as a multidimensional concept that involves several domains of well-being, is described as an “ethical imperative” (Campoli & Cummings, 2019, p. 11), whereby if left unmanaged, chronic stress can develop into burnout, which is predictive of poor ethical judgment and suboptimal care practices (Campoli & Cummings, 2019).
 
Self-care has been demonstrated as an effective tool to decrease physical and mental health concerns (Myers et al., 2012). Results of a meta-analysis indicated that individuals who practiced self-care reported significantly more benefits in their physical and mental health than those who did not, with an average effect size of d = .77 (moderate; Colman et al., 2016). While the effect sizes between studies varied, results indicated that effect sizes did not vary as a function of individual differences or type of self-care implemented (see Table 1 for multidimensional self-care ideas and strategies). Results from Myers et al. (2012) suggested that sleep hygiene, social support, emotion regulation strategies, and acceptance within a mindfulness framework were all significantly related to perceived stress. In addition to improvements in mental and physical well-being, self-care has been positively related to progress through graduate training (Zahniser, Rupert, & Dorociak, 2017), and in clinical outcomes with clients (Chui et al., 2016). Taken together, there is ample evidence to suggest that self-care is an appropriate antidote to the chronic stressors that are especially prevalent in psychological graduate training, which begs the question, what stands in the way of employing self-care?

Numerous barriers to self-care have been reported by graduate students, the largest of which being time, which was cited by over 71% of students, and finances (46%; El-Ghoroury et al., 2012). Additional reported barriers include concerns about confidentiality (if choosing to seek therapy; Dearing, Maddux, & Tangney, 2005; El-Ghoroury et al., 2012), perceived faculty support of self-care practices (Dearing, Madddux, & Tangney, 2005), and larger programmatic perceptions of prioritizing self-care (Goncher, Sherman, Barnett, & Haskins, 2013).

The self-care culture among psychology training sites needs improvement. In a survey of APA programs, over 60% of students reported that their program did not promote self-care (Munsey, 2006). In 2014, only 41% of training programs mentioned self-care in their program handbooks (Bamonti et al., 2014). The lack of prioritizing self-care in psychology training programs, in fact, reflect an area-wide pattern of self-care negligence in psychology, as psychologists reportedly ignore early-warning signs of burnout and consistently underestimate the importance and impact of self-care (Walsh, 2011). Importantly, in a survey of 260 clinical psychologists, 59% reported that they failed to seek therapy when they would have reportedly benefitted (Bearse, McMinn, Seegobin, & Free, 2013).

Where to from here? There are clearly several barriers to successfully engaging in self-care practices, from the programmatic to the individual level. Overcoming these barriers will also require supports and changes at the programmatic and individual level. Several recommendations are made below:

1. Use self-care as preventative language. Self-care is often discussed only after difficulties have occurred, or even after adverse consequences have already taken place (e.g., remediation; Carter & Barnett, 2014). Self-care should be discussed as a constant behavior, regardless of the status of performance in the program.
2. Self-care should be individualized to values, goals, and resources. Self-care strategies, while often displayed in a menu-type format such as the one above, often present students with an array of options and simply leave the choice up to them. According to this approach, self-care strategies should be universal; however, what is currently missing is an emphasis on how self-care activities integrate with an individual’s values and needs. Trainees should be encouraged to select activities that align with their values, as well as having greater likelihood to complete due to constraints (e.g., finances). In alignment with acceptance and mindfulness strategies, since values are chosen by the individual, choosing strategies that align with core values make it more likely that the strategy is carried out (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013).
3. Graduate programs should emphasize, model, and teach effective self-care strategies for all graduate students. Graduate programs can play a pivotal role in helping implement self-care strategies! Self-care training should occur, at the program-level, within the first semester of starting graduate training.
   1. Programs should include self-care language in their department handbooks and should normalize self-care seeking behaviors, including providing resources for confidential therapy should students elect to seek it.
   2. Programs should incorporate self-care as a program value, including modeling and discussion of barriers.
   3. Programs should offer experiential learning activities to promote self-care and increase exposure to unique self-care opportunities.
   4. Programs should elicit feedback from students to build self-care programmatic changes from the bottom-up.
   5. Clinical supervisors and mentors should use the privileged mentor-mentee relationship as a means to discuss and promote self-care.

 
Psychology graduate trainees, in particular, report higher levels of stress than the general public and than other graduate students. Self-care, while an effective tool to mediate the impacts of chronic stress, are often under-utilized and poorly recognized due to individual barriers (e.g., time, finances), and programmatic barriers (e.g., lack of support of self-care strategies, lack of confidentiality for seeking self-care strategies, and a lack of discussion at the department level). To fully reap the benefits of self-care, it is recommended that self-care be preventative, individualized, and emphasized at the graduate-level. Starting with just a few clinical psychologists can have a significant, positive ripple effect into our departments, programs, clinics, and communities.

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References

Bamonti, P. M., Keelan, C. M., Larson, N.,Mentrikoski, J. M., Randall, C. l., Sly, S. K.,…McNeil, D. W. (2014). Promoting ethical behavior by cultivating a culture of self-care during graduate training: A call to action. Training and Education in Professional Psychology, 8, 253-260. doi:10.1037/tep0000056.

Bearse, J. l., McMinn, M. R., Seegobin, W., & Free, K. (2013). Barriers to psychologists seeking mental health care. Professional Psychology: Research & Practice, 44(3), 150–157. doi:10.1037/200311182.

Campoli, J., & Cummings, J.A. (2019). Self-care in clinical psychology trainees: Current approach and future recommendations. ABCT: The Behavior Therapist, 42(1).

Carter, l. A., & Barnett, J. E. (2014). Selfcare for clinicians in training: a guide to psychological wellness for graduate students in psychology. New York, NY: Oxford University Press.

Chui, H., Hill, C. E., Kline, K., Kuo, P., & Mohr, J. J. (2016). Are you in the mood? Therapist affect and psychotherapy process. Journal of Counseling Psychology, 63, 405-418.doi:10.1037/cou0000155.

Colman, D. E., Echon, R., Lemay, M. S., McDonald, J., Smith, K. R., Spencer, J.,… Swift, J. K. (2016). The efficacy of self-care for graduate students in professional psychology: A meta-analysis. Training and Education in Professional Psychology, 10, 188-197. doi:10.1037/tep0000130.

Dearing, R. l., Maddux, J. E., & Tangney, J.P. (2005). Predictors of psychological help seeking in clinical and counseling psychology graduate Students. Professional Psychology: Research and Practice, 36, 323-329. doi:10.1037/0735-7028.36.3.323.

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Goncher, I. D., Sherman, M. F., Barnett, J.E., & Haskins, D. (2013). Programmatic perceptions of self-care emphasis and quality of life among graduate trainees in clinical psychology: The mediational role of self-care utilization. Training and Education in Professional Psychology, 7, 53-60. doi:10.1037/a0031501.

Hayes, S. C, Levin, M. E., Plumb-Vilardaga, J., Villatte, J. l., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44, 180-198. doi:10.1016/j.beth.2009.08.002

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Disclaimer: The views and opinions expressed in this newsletter are those of the authors alone and do not necessarily reflect the official policy or position of the Psychological Clinical Science Accreditation System (PCSAS).