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InPsych 2015 | Vol 37

Cover feature : Psychologist self-care

Integrating self-care instruction into professional psychology training

Self-care is important in preventing clinically significant distress that may lead to impairment, hence, there is an ethical imperative for psychologists to foster their own welfare. Professional psychology training programs therefore have a responsibility to explicitly teach self-care skills. Given that professional identity is formed during psychology training, integrating self-care into the formation of this identity is likely to benefit trainees later in their career. However, in practice self-care is usually presented to the trainee as an individual responsibility, rather than being taught directly.

As well as equipping trainees for their careers in psychology, self-care instruction can also address the numerous stressors in postgraduate psychology training. These challenges include academic evaluation, time constraints, competing demands of clinical, academic and research work, long hours, frequent switching between diverse roles (e.g., student, tutor and therapist), and the ambiguities inherent in psychology practice (Pakenham & Stafford-Brown, 2012). Postgraduate psychology students are therefore understandably susceptible to high stress, with prevalence rates for clinically significant distress among clinical psychology students ranging from 59–73 per cent (Stafford-Brown & Pakenham, 2012). Postgraduate psychology training, therefore, presents a teachable moment for the personal application of therapy skills learnt for professional practice. Furthermore, promoting self-care during training is likely to provide a foundation for career-sustaining self‑care practices that prevent burnout in later professional life.

Choosing the model for self-care instruction

Despite recognition of the need for training in self-care strategies for postgraduate students, research in this area is limited, with little progress in the evaluation of effective models for guiding self-care training.

Guidance on the model for self-care instruction during psychology training can be gleaned from the wide range of self-care guidelines recommended for psychologists, which are drawn from broad areas such as spiritual practices, mindfulness, therapeutic lifestyle changes, positive psychology, and practitioner-tested practices. In particular, ‘third wave’ cognitive and behaviour therapies based on mindfulness and acceptance processes, such as acceptance and commitment therapy (ACT), are suited to fostering self-care (Wise et al., 2012). The mindfulness-based positive principles and practice approach for promoting self-care recommended by Wise et al. (2012) is based on four principles: flourishing; intentionality in developing an evolving personal self‑care plan; embracing the reciprocity inherent in care of self and others; and the integration of self-care into daily routines.

ACT is an empirically supported treatment for many mental health problems (see reviews by Hayes et al., 2006; Ruiz, 2010). The ACT framework proposes six therapeutic processes that foster psychological flexibility (acceptance, cognitive defusion, contact with present moment [mindfulness], self-as-context, values, and committed action). The six processes are interrelated and overlapping, and can be grouped into two overarching processes: mindfulness and acceptance; and commitment and behaviour change. Consistent with the ACT framework, these processes are related to better mental and physical health outcomes (Hayes et al., 2006; Ruiz, 2010).

Self-care involves self-initiated practices that advance personal wellbeing. In view of the benefits associated with the ACT processes, the skills inherent in these may be regarded as self-care practices themselves. The ACT mindfulness and acceptance processes are largely directed to the nurturing of one’s inner experiencing and foster important prerequisites to self-care including self-awareness, self-regulation skills and the ability to balance one’s needs with those of others. For example, trainees who use acceptance and defusion strategies to manage stress may be less likely to exacerbate their distress through avoidance or struggling against it and, therefore, more likely to maintain manageable stress levels. In contrast, the ACT commitment and behaviour change processes are mainly associated with externally oriented self-care behaviours. For example, trainees who are connected and committed to their values across a wide range of life domains are more likely to engage in self-care behaviours, such as regular exercise, which are likely to lead to less stress and greater fulfilment.

There are several reasons why ACT is suited to fostering self‑care in psychology trainees. First, the theory underlying the ACT trans-diagnostic framework suggests human suffering largely stems from normal language and cognition processes that affect all humans, so both client and therapist can benefit from the ACT therapeutic processes. In this way, ACT explicitly encourages practitioners to practise the same strategies they use to help their clients.

Second, mindfulness has been identified as a key self-care practice, as evident from associations between greater mindfulness and lower stress in a range of mental health trainee populations (e.g., see review Pakenham & Stafford-Brown, 2012). Finally, ACT promotes a strong connection and commitment to values. Encouraging trainees to commit to their values across all areas of living is likely to bring about a commitment to positive lifestyle behaviours and a greater work-life balance. In support of the proposal that ACT is well suited to nurturing self-care in psychology trainees, the ACT processes have been shown to be related to better adjustment in clinical psychology trainees, including satisfaction with clinical psychology training (Pakenham, In press-a).

Self-care ACT training course

Based on the above reasoning and evidence, instruction in self‑care was integrated into an ACT course offered in the first year of postgraduate clinical psychology training at The University of Queensland. The course was first offered in 2009, and self-care training was formally introduced in 2011. The course consists of 12 weekly 2-hour workshops that include didactic instruction on the ACT processes, experiential exercises, and demonstration and practice role-plays.

In addition to acquiring ACT knowledge and competencies, an explicit course aim is to develop self-care skills. A ‘self-as-laboratory’ approach is adopted, whereby students are asked to practise and apply the ACT strategies personally through in-class experiential exercises and between-class ‘self-care practice tasks’. At the end of each workshop a self-care practice task is given and completion of this is discussed at the beginning of the following workshop. During these workshops, the course coordinator models and discusses his personal application of ACT processes and self-care practices.

In-class experiential exercises involve students exploring their values and setting related goals, and applying ACT strategies (e.g., defusion, acceptance and present awareness) to their private experiencing (e.g., thoughts, feelings and physical sensations). A workshop towards the end of the course is devoted to self-care and includes summaries of the research on stress and burnout in psychology trainees and psychologists, the adverse effects of stress on practitioner wellbeing and clinical practice and the ethical implications, self-care interventions (including practitioner-tested self-care strategies), and several experiential exercises including a loving kindness meditation. At the end of the workshop students are given time to begin compiling a sustainable career self-care plan.

Evaluation of ACT training course

Descriptive and qualitative data from 57 trainees enrolled in the course between 2011 and 2013 showed that all students found the course helpful in nurturing self-care, and 74 per cent reported one or more behavioural self-care changes. The most frequently reported self-care changes and helpful course components were related to the six ACT processes (Pakenham, In press-b). Statistical analyses showed that students reported improvements from before to after training on measures of self-care self-efficacy, self-compassion, acceptance, defusion, mindfulness, values, counselling self-efficacy, client-therapist alliance, and a marginally significant improvement on somatic symptoms, despite a trend towards increased stress (Pakenham, In press-b; In press-c).

ACT-based stress management intervention

Cultivating self-care in psychology trainees can also be achieved by standalone ACT interventions. A group ACT stress management intervention for clinical psychology trainees was evaluated as part of a doctoral research project using participants from four universities in south-east Queensland. Compared to a control group, intervention participants demonstrated greater increases in self-compassion, life satisfaction and the ACT processes, and greater reductions in distress and stress (Stafford-Brown & Pakenham, 2012). Importantly, some of the ACT processes mediated changes on the primary outcomes. Qualitative data from this study showed that intervention participants were keen to continue applying the ACT processes both personally and professionally (Pakenham & Stafford-Brown, 2013).

Other self-care instruction modes and contexts

Two strategies for encouraging self-care in psychology trainees within an ACT framework have been described, however, these strategies could be adopted within other therapeutic frameworks. There are also many other strategies for fostering self-care including prompting self-care in supervision. In fact, given the pivotal role of clinical supervision, integrating self-care into supervision should be a standard requirement.

Irrespective of the type of therapeutic approach or self-care promotion strategies used, explicit instruction in self-care should be provided and modelled during psychology training. However, self-care should not be prescribed or forced, but rather driven by one’s values because self-care is profoundly personal. The professional formative period early in professional psychology training is the optimal time to build foundational self-care practices and orientation. However, these self-care training approaches have wide application and can be used in other psychology education and workplace contexts. For example, a web-based ACT intervention for undergraduate psychology students will be trialed at The University of Queensland in the near future. This widely accessible program will focus on building basic self-care skills for promoting mental health.

Conclusions

Living can bring significant hardships that deplete our resources. Our imperfect histories can produce painful silent echoes that make us psychologically vulnerable at times. Training (or practising) as a psychologist does not make us invulnerable to these aspects of being human. Although the personal acquisition and application of therapeutic skills will not prevent brief or prolonged spikes in psychological distress, there is evidence indicating that such skills can help us (as they do our clients) ‘ride’ the rough times, and even flourish from them. They can also nourish the self-awareness necessary for making wise personal and professional decisions about how we manage our psychology practice during these stressful periods.

Given the resources and skills we acquire during psychology training, we can only benefit from a ‘practice what we preach’ approach and from ensuring that self-care is instilled in those entering the profession. A critical period for the development of self-care is at the first exposure to the stressors of psychological practice during professional training. The experience of clinical psychology trainees at The University of Queensland has demonstrated that both the standalone ACT intervention and the ACT training course were associated with increases in self‑compassion – a cornerstone of self-care. The two forms of self-care instruction were also associated with increased engagement in values‑driven living – indicative of flourishing. What a great foundation for embarking on a sustainable career in psychology!

The author can be contacted at k.pakenham@psy.uq.edu.au.

References

  • Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1-25.
  • Pakenham, K. I. (In press-a). Investigation of the utility of the acceptance and Commitment Therapy (ACT) framework for fostering self-care in clinical psychology trainees. Training and Education in Professional Psychology.
  • Pakenham, K. I. (In press-b). Training in Acceptance and Commitment Therapy fosters self-care in clinical psychology trainees. Clinical Psychologist.
  • Pakenham, K. I. (In press-c). Effects of Acceptance and Commitment Therapy (ACT) Training on clinical psychology trainee stress, therapist skills and attributes, and ACT processes. Clinical Psychology and Psychotherapy.
  • Pakenham, K. I. & Stafford-Brown, J. (2013). Postgraduate clinical psychology students’ perceptions of an ACT stress management intervention and clinical training. Clinical Psychologist, 17, 56-66.
  • Pakenham, K. I. & Stafford-Brown, J. (2012). Stress in clinical psychology trainees: current research status and future directions. Australian Psychologist, 47, 147-155.
  • Ruiz, F. J. (2010). A review of acceptance and commitment therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10, 125-162.
  • Stafford-Brown, J. & Pakenham, K. I. (2012). The effectiveness of an ACT informed intervention for managing stress and improving therapist qualities in clinical psychology trainees. Journal of Clinical Psychology, 68(6), 592-613.
  • Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487-494.

Disclaimer: Published in InPsych on February 2015. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.