Professional Psychology: Research And Practice

Psychotherapist Self-Care Practitioner-Tested, Research-Informed Strategies

John C. Norcross Department of Psychology University of Scranton

Psychotherapists, by definition, study and modify human behavior. That is, we study and modify other humans. Psychological principles, methods, and research are rarely brought to bear on therapist themselves, with the probable exception of our attempting to diagnose one another. Although understandable and explicable on many levels, the paucity of systematic study on psychotherapists' self-care is unsettling.

Self-care and self-change have occupied a sizeable portion of my professional career and, not coincidentally, my personal life. Dr. Robert Brown and I have commissioned and edited articles for the Self-Care Corner during the past year, for instance. Over the past 2 decades, colleagues and I have conducted numerous studies to identify what distinguishes the self-change of mental health professionals from that of educated laypersons, to survey practitioners about what they use and do not use to soothe themselves, and to interview seasoned psychotherapists about their personal struggles and salvations. We have taken the Socratic dicta of "know thyself" and "heal thyself" to heart–and to the lab (for summaries of this research, see Brady, Healy, Norcross, & Guy, 1995 ; Brady, Norcross, & Guy, 1995; Guy, Freudenberger, Farber, & Norcross, 1990 ; Norcross & Aboyoun, 1994 ; Norcross & Guy, 1989 ; Norcross & Guy, in press ; Norcross, Strausser, & Missar, 1988 ; Prochaska, Norcross, & DiClemente, 1995 ).

The resulting compilation of self-care strategies is clinician recommended, research informed, and practitioner tested. In the scientist—practitioner tradition, we have tried to meld psychotherapists' in- the-trenches recommendations with the nascent empirical findings. Here, in outline form, are 10 consensual self-care strategies, with a few illustrative examples from my own practice and life, as I struggle to practice what I preach (and research):

 Recognize the hazards of psychological practice. Begin by saying it out loud: Psychotherapy is often a grueling and demanding calling. A growing body of empirical research attests to the negative toll exacted by a career in psychotherapy. Although each of us experience distress differently, the literature points to moderate depression, mild anxiety, emotional exhaustion, and disrupted relationships as the common residue of immersing ourselves in the inner worlds of distressed and distressing people ( Brady, Healy, et al., 1995 ). In Freud's (1905/1933) words, "No one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human breast, and seeks to wrestle with them, can expect to come through the struggle unscathed" (p. 184).

Perhaps the most significant benefit to be achieved from openly acknowledging the strains of practicing psychotherapy is the realization that virtually all mental health professionals experience similar kinds of pressure. Confidentiality, isolation, shame, and a host of additional considerations lead us to overpersonalize our own sources of stress, when in reality they are part and parcel of the common world of psychological work. Disconfirming our individual feelings of unique wretchedness and affirming the universality of the hazards are in and of themselves therapeutic. Moreover, appreciating the universality and accepting some of the inevitable distress associated with conducting psychotherapy contribute to the creation of corrective actions.

 Think strategies, as opposed to techniques or methods. One of the overarching lessons from our research is that effective psychotherapist self-change is characterized by a complex, differential pattern of change strategies ( Prochaska et al., 1995 ). These strategies or principles represent an intermediate level of abstraction between concrete techniques and global theory. Given the diversity of individual preferences and available resources, we recommend broad strategies as opposed to specific techniques. For example, if a colleague is plagued by occupational anxieties, the research suggests that the strategies of counterconditioning and helping relationships may well prove effective. Once the strategies are identified, then individual practitioners can discover for themselves the available and preferred techniques for implementing these strategies. For instance, massage, exercise, and meditation for counterconditioning and peer support groups or clinical supervision for helping relationships.  Begin with self-awareness and self-liberation. Quantitative studies and interview surveys alike confirm the conventional wisdom on the centrality of self-monitoring our own distress level. In one illustrative study, both program directors and professional psychologists identified "self- awareness/self-monitoring" as the top-ranked contributor to optimal functioning among psychologists ( Schwebel & Coster, 1998 ). For some of us, this self-monitoring requires that we also attend to interpersonal feedback from significant others about our functioning. In my case, I attend to my wife's observations that I am looking haggard, working longer hours, or traveling too often to supplement my own monitoring.

In several of our studies devoted to discovering the successful self-change strategies of psychotherapists, self-liberation–a fancy name for choosing and self-realization–consistently emerged as an effective process. This process entails the choice of changing and the ensuing responsibility. It is the acknowledgement, the commitment, and the burden of replenishing yourself, professionally and personally.

 Embrace multiple strategies traditionally associated with diverse theoretical orientations. In at least four studies, we have been unable to identify differences among psychotherapists in their own self-change as a function of their theoretical orientation (see Norcross & Aboyoun, 1994 , for a review). We failed to find even the few statistically significant differences expected by chance alone. At the same time, psychotherapists' effective self-care strategies identified in research hail from a number of diverse orientations. The effective strategies are those historically associated with behavioral, experiential, psychodynamic, and systemic traditions. In other words, the composite findings strongly argue for a considerable degree of similarity among psychotherapists in "what works" across the theoretical continuum. Although these research results can be interpreted cynically–the duplicity between psychotherapists' public careers and their personal lives, for example–I prefer to conclude positively that psychotherapists become more pragmatic, secular, and eclectic when confronting their own distress.

Furthermore, our research has shown appreciable outcome differences between various psychotherapist self-change strategies, but at the same time, the effect of any single self-change strategy is rather modest. These findings suggest to us, as they have to other researchers examining coping among laypersons, that possessing a particular skill in one's arsenal is less important than having a variety of self-change skills. Seasoned practitioners have extended valuable lessons from their clinical work to their personal lives: Avoid concentration on a single theory and promote cognitive and experiential growth on a broad front ( Goldfried, in press ).

 Employ stimulus control and counterconditioning when possible. Our investigations have determined that certain self-change strategies are differentially effective and adaptive for psychotherapists; of course, the conclusions are grounded in the context of our methodology, outcome criteria, time frame, and other design considerations. But the results consistently point to the use of two action-oriented strategies.

First, the frequency with which psychotherapists modify their environments with stimulus control methods consistently correlates with effectiveness. Make your environment work for you, not against you. Years ago, I learned that I was happier spending extra overhead expenses to maintain a large, comfortable office and to have an office manager handle all financial and billing matters. Yes, I net less private practice income, but I enjoy my clinical work and therapy environment much more. How is your environment enhancing or detracting from your practice?

It is ironic that stimulus control is one of the least frequently used strategies among psychotherapists. Adept at maintaining interpersonal boundaries, practitioners frequently ignore the environmental practicalities that profoundly influence their satisfactions. Harness the subtle but pervasive power of the environment to replenish yourself.

Second, research has identified the broad strategy of counterconditioning as a reliable predictor of effective self-change among mental health professionals. The classic methods under this strategy include relaxation, assertion, cognitive restructuring, exercise, and diversion–all action-oriented, skill-building methods designed to address the problem forthright. My own preferences run to massage for relaxation, reading and films for diversion, and basketball and tennis for exercise. Whether you directly ask clinicians to nominate what maintains their well functioning or indirectly correlate their in-session behavior to subsequent mood, problem- focused strategies are always near the top of the list.

 Emphasize the human element. Psychotherapists have probably internalized advice for improving the therapeutic product: Emphasize the interpersonal element in their own self-care. In several of our studies, mental health professionals consistently report greater use of helping relationships than educated laypersons in dealing with their own distress. In related studies, increased use of helping relationships correlates positively with effective self-care–just as the use of social support typically does with laypersons. Expectedly, psychotherapists find helping relationships to be both satisfying and efficacious for themselves. As with any of these broad strategies, the number and range of techniques are impressive–peer groups, loving relationships, close friendships, clinical supervision, and so on.  Seek personal therapy. It is well established and widely known that the majority of mental health professionals, with the exception of biologically oriented psychiatrists, have sought personal therapy. What is equally well established but not widely known is that (a) more than half of psychotherapists following completion of their training utilize the very service they provide and (b) the vast majority of mental health professionals–90% plus–rate the outcomes of personal therapy quite positively. It is an illusion, or perhaps a delusion, that most mental health professionals do not experience a need for personal therapy once they are in practice. It is a disquieting myth that personal therapy is frequently regarded as a failure. Our studies consistently find that psychotherapists regularly recommend, seek, and value episodic personal therapy as constructive self-care. Freud (1937/1964) anticipated this research finding years ago:

Every analyst should periodically–at intervals of five years or so–submit himself to analysis once more, without feeling ashamed of taking this step. This would mean, then, that not only the therapeutic analysis of patients but his own analysis would change from a terminable into an interminable task. (p. 249)

 Avoid wishful thinking and self-blame. Our studies have identified not only what predicts effective self-care but also what correlates with ineffective self-care–the "to do" as well as the "not to do." Two coping strategies reliably associated with self-care ineffectiveness among psychotherapists are wishful thinking and self-blame. By focusing on their not being able to change and relying on wishing rather than acting, the former probably accentuates distress and reduces problem solving. In a similar way, the negative preoccupation of self-blame may distress the therapist further and paralyze adaptive resources.  Diversify, diversify, diversify. In extrapolating from the empirical research on psychotherapist self-care and from mental health professionals' writings on self-renewal, I discern a recurring theme: the diversity and synergy of professional activities. The diversity is grounded in conducting multiple forms of therapy (e.g., individual, couples/family, group therapy), engaging in multiple activities (e.g., psychotherapy, assessment, research, teaching, supervision, consultation), working with multiple types of patients and problems (e.g., age, ethnicity, disorders), and balancing professional responsibilities with personal needs. For myself, I have made similar decisions to diversify; for example, combining a part-time practice with a teaching and research career, alternating individual psychotherapy sessions of high socioeconomic status mental health professionals with pro bono group therapy of chronic pain patients, and relentlessly juggling professional responsibilities and personal needs.  And appreciate the rewards. Finally, in coming full circle, the hazards of psychological practice must be reconciled and balanced with its privileges. Clients are not the only ones changed by psychotherapy. Compared with researchers, practitioners are more satisfied with their lives and more likely to feel that their work has influenced them in positive ways. In one recent study ( Radeke & Mahoney, 2000 ), psychotherapists related that the impact of their work has made them better, wiser, more aware; accelerated their psychological development; increased their capacity to enjoy life; and felt like a form of spiritual service.

The practitioner who denies that clinical work is grueling and demanding is, in Thorne's (1989) words, mendacious, deluded, or incompetent. I would also add that the therapist who claims not to have personally benefited from this grueling work is also likely to be mendacious, deluded, or incompetent. Without trivializing the strains of this "impossible profession," practitioners would do well to remember that the vast majority of mental health professionals are satisfied with their career choices and would select their vocations again if they knew what they know now. Most of our colleagues feel enriched, nourished, and privileged in conducting psychotherapy. The work brings relief, joy, meaning, growth, vitality, excitement, and genuine engagement, both for our patients and for us. Lose not these moorings amidst the inevitable strains of practice and the rising industrialization of our craft. References

Brady, J. L., Healy, F. L., Norcross, J. C. & Guy, J. D. (1995). Stress in counselors: An integrative research review.(In W. Dryden (Ed.), Stress in counselling in action (pp. 1—27). Newbury Park, CA: Sage.) Brady, J. L., Norcross, J. C. & Guy, J. D. (1995). Managing your own distress: Lessons from psychotherapists healing themselves.(In L. VandeCreek, S. Knapp, & T. L. Jackson (Eds.), Innovations in clinical practice (pp. 293—306). Sarasota, FL: Professional Resource Press.) Freud, S. (1933). Fragment of an analysis of a case of hysteria.(In Collected papers of Sigmund Freud (Vol. 3). London: Hogarth. (Original work published 1905)) Freud, S. (1959). Further recommendations in the treatment of psychoanalysis: On beginning the treatment.(In Collected Papers of Sigmund Freud. (Vol. 2). New York: Basic.) Freud, S. (1964). Analysis terminable and interminable.(In J. Strachey (Ed.), Complete psychological works of Sigmund Freud. London: Hogarth. (Original work published 1937)) Goldfried, M. R. (Ed.) (in press). How therapists change: Personal and professional recollections. (Washington, DC: American Psychological Association) Guy, J. D., Freudenberger, H., Farber, B. & Norcross, J. C. (1990). Hazards of the psychotherapeutic profession. Psychotherapy in Private Practice, 8, 27-61. Norcross, J. C. & Aboyoun, D. C. (1994). Self-change experiences of psychotherapists.(In T. M. Brinthaupt & R. P. Lipka (Eds.), Changing the self (pp. 253—278). Albany, NY: State University of New York Press.) Norcross, J. C. & Guy, J. D. (1989). Ten therapists: The process of becoming and being.(In W. Dryden & L. Spurling (Eds.), On becoming a psychotherapist (pp. 215—239). London: Routledge.) Norcross, J. C. & Guy, J. D. (in press). Leaving it at the office: Psychotherapist self-care. (New York: Guilford Press) Norcross, J. C., Strausser, D. J. & Missar, C. D. (1988). The processes and outcomes of psychotherapists' personal treatment experiences. Psychotherapy, 25, 36-43. Prochaska, J. O., Norcross, J. C. & DiClemente, C. C. (1995). Changing for good. (New York: Avon) Radeke, J. T. & Mahoney, M. J. (2000). Comparing the personal lives of psychotherapists and research psychologists. Professional Psychology: Research and Practice, 31, 82-84. Schwebel, M. & Coster, J. (1998). Well-functioning in professional psychologists: As program heads see it. Professional Psychology: Research and Practice, 29, 284-292. Thorne, B. (1989). The blessing and curse of empathy.(In W. Dryden & L. Spurling (Eds.), On becoming a psychotherapist (pp. 53—68). London: Routledge.)

I gratefully acknowledge the feedback of Robert Brown, Marvin Goldfried, and James Guy on an earlier draft of this article. Correspondence may be addressed to John C. Norcross, Department of Psychology, University of Scranton, Scranton, Pennsylvania, 18510-4596. Electronic mail may be sent to [email protected]