Counseling Today, Member Insights

Self-care in the world of empirically supported treatments

By Dolores “Lori” Puterbaugh May 28, 2015

One of the many profound changes within the counseling profession for mental health counselors has been a gradual shift from psychodynamic and person-centered therapies to an emphasis on the medical model. The full history of this shift is an interesting one, featuring as much sociopolitical Checklist-face_smallinfluence as scientific influence, but that is beyond the scope of this article. The end result of this shift is a focus on diagnosing and matching treatment interventions to the diagnostic criteria. Those who were focused on efficacy and efficiency in the early stages might never have imagined the unintended consequences of their best intentions.

Today, our graduate students are preparing to work in a world in which diagnosing according to the latest established criteria and then matching the appropriate brief, empirically supported interventions to those diagnoses are paramount. For students and new professionals, this reductionist approach might make it seem as if mental health treatment is a very straightforward process of applying Technique A to Problem B.

Medicalized mental health frames diagnostic criteria as signs of illness to be wiped out rather than indicators of pain to be uncovered, addressed and integrated. Symptoms are problems in themselves rather than signs of problems of being. This mechanization of mental health care can have strange effects on counselors. One in particular — the focus of this discussion — is the stultifying effect that reductionism can have on self-care.

Self-care is a standard topic in introductory graduate counseling courses, practicum courses, internship supervision sessions, professional trainings and the professional literature. Nearly every week, I receive invitations to participate in a survey on self-care for dissertation research and receive several offers of continuing education courses on the same topic. Ubiquitous a topic as self-care may be, the definition seems to be so broad that, as with a client’s complaint of depression, no two people can be sure that they really understand what the other is subsuming when the murky phrase “self-care” is introduced.

In recent research focused on grief counseling, not yet published, I surveyed counselors ranging from new professionals (less than five years of postgrad experience) to the seasoned (20 years of experience or more). The sample size was quite small, minimizing the generalizability of the findings. Still, one aspect in particular piqued my curiosity: the tendency among less experienced practitioners to confound recreation with self-care. Although recreation is part of self-care, it is not synonymous with the full range of internal and external attention that constitutes all of self-care.

Another pattern in the research was the assertion, most common among newer professionals in my small pool of respondents, that the right intervention (in this case, within grief counseling) would come naturally and they would know what to do or say in session without concern. More experienced therapists were far less likely to subscribe to this option because they shared an awareness that within (grief) counseling there is no single “right” answer that will naturally come to the foreground. In short, the less experienced counselors were more likely to oversimplify self-care and to have a great deal of confidence that they would simply know what to do when faced with client issues in grief counseling. More experienced counselors were more likely to cite a variety of self-care strategies and to be less confident that the correct intervention would simply rise to the surface during counseling.

I suspect the disparate attitudes between cohorts rests in part on the increasing emphasis on empirically supported interventions and psychiatry’s ongoing reductionist approach to the richness of human experience. We do very well in ensuring that our students know the diagnostic criteria and the most recent research-supported, efficacious interventions that match those criteria. However, we are into perhaps a second generation of counselors who are proceeding with protocols developed by others who are blind to the section of the Johari window that comprises all that is unknown.

Taking a shallower approach

A mere two counselor generations ago, our education and training were solidly grounded in psychodynamic theories, with a tremendous emphasis on self-awareness, therapy for therapists and a profound respect for the depth and breadth of the field of therapy. The power of the relationship was emphasized, and this has not lost its importance, as evidenced by the keynote session presented by Jeffrey Kottler and Richard Balkin at the 2015 ACA Conference & Expo in Orlando, Florida. The developers of what comprise the brief therapies were well-grounded in psychodynamic theory.

Subsequent generations of counselors more often give a drive-by nod to theories that involve the unconscious aspects of experience. They can easily be misled to believe that the readily accessed cognitions are all there are to the client’s misconceptions. Unaware of how a leader such as Donald Meichenbaum’s deep knowledge of psychodynamics colors his current research and work with posttraumatic stress disorder, the new practitioner is prone to merely parroting technique. Meichenbaum, or a therapist with a similar depth and breadth of knowledge, will hear subtle cues about the client’s stability, insecurities, capacity for abstract thought and ability to tolerate frustration or ambiguity and then make nuanced adjustments to interventions on the basis of these minute variations in individual functioning. Meanwhile, a counselor whose education has been aimed at providing empirically based interventions for specific diagnoses is tightly gripping the hammer of cognitive-based therapies, in which every problem is a simple case of irrational belief or cognitive distortion to be thumped into a more logical shape.

Is there a risk that a superficial approach in one area will ineluctably contaminate others? Will the new counselor, ill-prepared to wade into the depths of the client and holding an empirically defended disregard for the importance of those depths, mirror this with a lack of insight into the depth of the self?

Many graduate students and new practitioners have taken advantage of personal therapy and other opportunities for reflection and growth. However, when I review a taped session with a counselor-in-training and my question “What was/is going on for you right now in the session?” is met with a blank stare or a recitation of the relationship between the intervention and the client’s issue, I suspect that insight into the internal experience of the counselor was a chapter only skimmed during formation.  Likewise, countertransference was reduced to a mere vocabulary word or reflexively described as a source of ethical violations. It is rarely considered a source of useful insight when handled properly and brought to supervision, consultation or the counselor’s own therapy session.

When I encounter insufficiency in attending to internal experiences (in counselors and in clients), that insufficiency often co-occurs in the realm of self-care. How, then, do we bridge the gap for students, interns and new practitioners who are attempting to meet the self-care needs of a counselor’s heart, mind and soul through lighthearted socializing or with a stroll in the park?

A superficial model of self-care

The awareness of a need is required before any meaningful attempt to meet that need will be taken. The counselor who has decided that emotions regarding clients are “wrong” because they signify “countertransference,” and subsequently attempts to ignore or suppress those responses to the client, is at risk for the very problems that countertransference can spur. Similarly, self-care requires quiet times for reflection, but a counselor who has absorbed the societal bias against introverted behavior may mislabel these quiet times as “isolating.” Busy students and practitioners — like so many of our clients — can no doubt find multiple reasons, from lack of time to lack of finances, to postpone individual therapy, spiritual guidance and peer supervision.

Yet lack of reflection feeds into a deeper ocean of lack of insight. Meanwhile, self-care, dumbed down to socializing and recreational pursuits, skips lightly over the surface, not sinking into the opportunity for deep reflection and its rewards, including insight into self and others. Self-care gets reduced to time spent relaxing with television or friends or, more rarely, exercising or playing outdoors. These are aspects of self-care, but they elude the essence and responsibility we have for a well-rounded and consistent habit of true self-care.

Our professional literature and conferences are rich with articles and experiential trainings on the importance of deep, well-rounded self-care that addresses the whole person: body, mind and spirit. One suspects that, overstretched and desperately in need of self-care, a great many counseling graduate students, interns and professionals are failing to give more than a cursory glance at these offerings because life is overwhelming. Using a superficial model of self-care, they throw interventions at themselves the same way we are trained to toss interventions at client complaints. As with the empirically supported interventions of therapy, many self-care interventions are focused on the immediate, conscious needs — for example, I need to unwind/blow off steam/throw my head back and laugh until my sides ache. These are indeed real aspects of self-care, but they are not sufficient on their own.

I suggest, then, that frequently shallow practices of self-care and the potential problems of relying on menu-driven, empirically supported interventions are not random parallel processes. They are one regrettable, predictable outcome of an efficiency-focused, reductionist approach to mental health that is not reflective of mental health counseling as a profession. Counselors are historically holistic, incorporating relationships, client strengths and insight into development with an understanding of pathology and treatment.

The current reductionist approach has been imposed on us by larger forces: third-party payers and the American Psychiatric Association. Meanwhile, our accreditation boards continue to emphasize proper formation, and mental health counseling graduate programs always feature foundational courses that include self-care. We must frequently revisit what is meant by self-care, as well as the implications of the various aspects of self-care for personal and professional functioning.

Client care and self-care ought to be rooted in a deep understanding of the human experience and a profound respect and reverence for the unknowable in each of us. A comprehensive self-care practice feeds our deep need to reflect, make meaning from the events of our lives and develop deep connections with others. Information on self-care and its many vital facets is readily available; we must ensure that the next generations of counselors integrate holistic care of the self into the fabric of their beings and the texture of their lives.

 

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A whole-person approach to self-care

The ways in which we meet our self-care needs will vary. The unique preferences, temperament and style of each counselor require a nuanced approach to self-care. Whatever your style, good self-care will encompass the following elements.

Physical: Strive for good nutrition, regular medical care, adequate sleep and appropriate exercise on a regular basis. Choose a few activities that suit your physical condition and temperament. For example, an extrovert might not enjoy long solo runs, whereas an introvert may relish the alone time for reflection and time in nature. Frequency: Daily practices.

Psychological: Have colleagues with whom you can meet and debrief on a regular basis. Consult with others. Have a therapist or supervisor to help you process the issues raised by your work with clients. Frequency: Weekly, meaningful interaction with colleagues or supervisors.

Social: Meet your social needs in the ways that suit your personality. Failure to meet your social needs outside of therapy will leave you vulnerable to meeting your needs in the therapy room. Frequency: Know your personality and adjust accordingly. Extroverts will need more contact to feel refreshed, whereas introverts will need more quiet after a day of interaction.

Emotional: Have a few people with whom you can be emotionally honest and feel the safety of mutual support. Frequency: Daily contact of some kind with a member of your inner circle.

Creativity: Seek a regular outlet for creativity that is wholly separate from the creativity required in the therapy room. Thinking outside the box in one area will enhance your creativity in the professional area, and investing energy into this kind of play is a way to refuel your spirit. From gardening, woodwork and music to haiku, drawing and cake decorating, the options are endless. Frequency: At minimum, a session of at least a couple of hours once per week.

Intellectual: Years ago, an instructor advised me to expect to spend 10 percent of my professional time reading and learning for the rest of my career. Make a habit of trying to learn something new about the profession every week. Frequency: Ten percent of the time you spend working, which includes reading, watching truly educational video presentations and earning continuing education units.

Spiritual: Nurture this aspect of yourself through whatever discipline is appropriate, whether it is the observation of an established religion or spending adequate time for reflection, meditation and quiet separateness from the busyness of life. Frequency: Daily.

Sound like a lot? We ask this of our clients; perhaps asking less of ourselves is not asking enough.

Imagine yourself well-fed, well-exercised and well-rested. You are regularly surrounded by supportive and insightful colleagues and have a safe place in which to explore your thoughts, feelings and memories as affected by counseling clients. You enjoy regular, meaningful contact with the people you love. You find your creativity blossoming in ways you may not have enjoyed since childhood — or certainly not since graduate school — and your counseling skills seem rejuvenated. At the same time, a regular stream of new ideas and research informs your work and challenges you to stretch your portfolio of techniques. With all this constant growth and change, the quiet time you spend in reflection, meditation, prayer or journaling becomes all the more precious as a way to integrate the totality of your life.

This is the self-care we want for our clients, our loved ones, our students, our colleagues and, yes, for ourselves.

 

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Dolores “Lori” Puterbaugh is a licensed mental health counselor and licensed marriage and family therapist who has been in private practice since 1999. She is an approved supervisor for registered mental health counseling and marriage and family therapy interns in Florida and teaches undergraduate and graduate courses in counseling and psychology. Contact her at puterbaugh@mindspring.com or visit her website at drloriputerbaugh.com.

Letters to the editor: ct@counseling.org

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