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Abstract

It is well-accepted that occupational hazards are endemic to the profession of psychology and that psychologists bring both strengths and vulnerabilities to their choice of career. Given the pressures faced by psychologists in contemporary society, how can we most effectively meet our ethical obligation to maintain competence throughout our professional life span in order to provide high quality care to those we serve? In this article, we propose to expand the current conceptualization of psychologist functioning as embodied in the widely promulgated stress-distress continuum. Through the incorporation of a positive dimension, we can envision the potential for psychologists to spiral up via their practice of enhanced self-care. Four foundational principles are interwoven throughout our consideration of effective self-care for psychologists: an emphasis on flourishing (rather than merely surviving), intentionality, an awareness of reciprocity in care of self and others and the benefits of integrating self-care into our daily practices and routines, rather than being added onto existing personal and professional obligations. A review of the literature on psychologist self-care strategies, healthy lifestyles, mindfulness, acceptance-based therapies, and positive psychology informs our endorsement of mindfulness-based positive principles and practice (MPPP's) for psychologists. These MPPP's are broadly conceptualized as the how of effective self-care that supports the what (as in what to do) in this realm. Finally, we envision a future in which effective self-care embedded in MPPP's is truly valued, supported and promoted by the profession in a manner that complements and sustains our ongoing well-being and professional competence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Ethics, Self-Care and Well-Being for Psychologists:
Reenvisioning the Stress-Distress Continuum
Erica H. Wise
University of North Carolina at Chapel Hill Matthew A. Hersh
Somerville, Massachusetts
Clare M. Gibson
Veterans Affairs Maryland Health Care System
It is well-accepted that occupational hazards are endemic to the profession of psychology and that
psychologists bring both strengths and vulnerabilities to their choice of career. Given the pressures faced
by psychologists in contemporary society, how can we most effectively meet our ethical obligation to
maintain competence throughout our professional life span in order to provide high quality care to those
we serve? In this article, we propose to expand the current conceptualization of psychologist functioning
as embodied in the widely promulgated stress-distress continuum. Through the incorporation of a positive
dimension, we can envision the potential for psychologists to spiral up via their practice of enhanced
self-care. Four foundational principles are interwoven throughout our consideration of effective self-care
for psychologists: an emphasis on flourishing (rather than merely surviving), intentionality, an awareness
of reciprocity in care of self and others and the benefits of integrating self-care into our daily practices
and routines, rather than being added onto existing personal and professional obligations. A review of the
literature on psychologist self-care strategies, healthy lifestyles, mindfulness, acceptance-based therapies,
and positive psychology informs our endorsement of mindfulness-based positive principles and practice
(MPPP’s) for psychologists. These MPPP’s are broadly conceptualized as the how of effective self-care
that supports the what (as in what to do) in this realm. Finally, we envision a future in which effective
self-care embedded in MPPP’s is truly valued, supported and promoted by the profession in a manner that
complements and sustains our ongoing well-being and professional competence.
Keywords: ethics, competence, well-being, self-care, mindfulness
As professional psychologists, we are committed to caring for
others and derive great satisfaction from these activities. However,
is this satisfaction sufficient—in and of itself—to sustain us
throughout a professional career? As a profession we tend to
neglect the importance of creating a sustainable balance between
caring for our clients and caring for ourselves. The wisdom tradi-
tions have long recognized the interrelatedness of care for the self
and care for the other. The oft-repeated 2,000-year-old quotation
attributed to Rabbi Hillel the Elder, effectively captures this es-
sential dialectic: “If I am not for myself, who will be for me? If I
am only for myself, what am I? And, if not now, when?”
In this article we will discuss how psychologists can be for
themselves as well as for their clients. We believe that the time has
come for us to take an honest, compassionate, and unflinching look
at the role of self-care and well-being in professional psychology.
In this article, which is based in part on a continuing education
workshop developed by the first author (Wise & Gibson, 2012),
we make the case that self-care is an ethical imperative as it relates
to competence. We will review the theoretical and research liter-
ature on psychologist vulnerabilities and propose a positive dimen-
sion to the traditional stress-distress continuum. In addition, we
will outline a comprehensive approach to self-care for psycholo-
This article was published Online First August 27, 2012.
ERICA H. WISE received her PhD in clinical psychology from Southern
Illinois University at Carbondale. She is director of the psychology training
clinic and clinical professor in the department of psychology at University
of North Carolina at Chapel Hill. Her professional interests include pro-
fessional education and training and the integration of ethics, diversity and
self-care into academic and professional practice settings.
MATTHEW A. HERSH received his PhD in clinical psychology from Uni-
versity of North Carolina at Chapel Hill. He maintains an independent
practice in Somerville, MA, engaging in mindfulness- and acceptance-
based psychotherapy for anxiety and mood difficulties. He also consults to
organizations to facilitate participants’ stress management, self-care, and
well-being. His research interests include mindfulness therapies, contem-
porary psychotherapy issues, and mind–body wellness.
CLARE MARKS GIBSON completed her doctoral studies at the University
of North Carolina at Chapel Hill and an internship with the Veterans
Affairs Maryland Health Care System. She will be starting a postdoc-
toral fellowship in psychosocial rehabilitation at the Veterans Affairs
Connecticut Health Care System. She has written on the topic of
self-care in clinical psychology graduate students and spoken at na-
tional conferences and local workshops.
WE THANK our colleagues, Meredith J. Mayer and Steven D. Mullinix,
for their many contributions to our conceptualization of psychologist
self-care and Jean A. Carter for her invaluable editorial assistance.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Erica
H. Wise, Department of Psychology, CB #3270, University of North
Carolina at Chapel Hill, Chapel Hill, NC 27599-3270. E-mail: ewise@
email.unc.edu
Professional Psychology: Research and Practice © 2012 American Psychological Association
2012, Vol. 43, No. 5, 487–494 0735-7028/12/$12.00 DOI: 10.1037/a0029446
487
gists based on mindfulness practices, values-oriented acceptance-
based therapies, and positive psychology. As you read this article,
we encourage you to be mindful of the interplay between care of
the self and care of the other.As we mentor graduate students,
interns, and early career psychologists, it is important to encourage
them to care for and sustain themselves as they enact their deep
commitment to becoming dedicated and competent professional
psychologists. As suggested by Rabbi Hillel, we believe that
caring for ourselves and others is an inherently integrated and
reciprocal process. And—as asked so cogently by Rabbi Hillel—
“if not now, when?”
Foundational Principles
As we envision a positive dimension to the stress-distress con-
tinuum, we believe that effective self-care for psychologists must
be broadly conceived and oriented toward sustainability and work-
ability. To assist psychologists in integrating ongoing attitudes and
practices that support well-being and self-care, we suggest four
foundational principles. First is the notion of surviving versus
flourishing (Keyes, 2002). When we focus on surviving, we inad-
vertently maintain a barely good enough status quo and fixate on
preventing the negative. In contrast, when we aspire to flourish,we
invite a broader array of possibilities into our personal and pro-
fessional lives, and we emphasize resilience-building attitudes and
practices that reflect an overarching positive orientation. Second is
the act of intentionally choosing our self-care plan over time and
being willing to change our attitudes and practices if (or as) they
become unworkable. Third is the concept alluded to above that we
have termed reciprocity, or the process of dynamic exchange of
beneficial lifestyle attitudes and practices between psychologist
and client. Fourth, we encourage the use of self-care strategies that
are integrated into rather than added onto our already busy and
stressful lives. These foundational principles are integrated and
interwoven throughout our discussion of mindfulness-based prac-
tices and principles (MPPPs).
Is Self-Care an Ethical Imperative?
Positive, intentional, integrated, and sustainable self-care is
clearly important. But is self-care also an ethical obligation? Self-
care—in the sense of enhancing positive well-being—is not di-
rectly addressed in the American Psychological Association
(APA) Ethics Code (APA, 2002). Competence, however, is an
essential ethical obligation and provides a critical link between
ethics and self-care. In the enforceable sections of the code,
Section 2 contains the ethical standards that relate to competence.
Standard 2.01, Boundaries of Competence (a) states the basic
expectation that Psychologists provide services, teach, and conduct
research with populations and in areas only within the boundaries
of their competence, based on their education, training, supervised
experience, consultation, study, or professional experience”(APA,
2002, p. 1063, emphasis added). Standard 2.03, Maintaining Com-
petence, reminds us that “Psychologists undertake ongoing efforts
to develop and maintain their competence” (APA, 2002, p. 1064,
emphasis added). The importance of competence and the critical
role of continuing professional development have been increas-
ingly recognized and promulgated in our field in recent years (e.g.,
Fouad et al., 2009;Roberts, Borden, Christiansen, & Lopez, 2005;
Wise et al., 2010).
The last sentence of General Principle A: Beneficence and
Nonmaleficence captures an essential component of the interface
between competence and personal wellness: “Psychologists strive
to be aware of the possible effect of their own physical and mental
health on their ability to help those with whom they work” (APA,
2002, p. 1063). Standard 2.06, Personal Problems and Conflicts, is
clearly focused on the potential negative impact that personal
problems may have on professional competence and on protecting
those with whom we work. In contrast, expanding the notion of
ongoing efforts as currently delineated in Standard 2.03 to include
a focus on personal wellness, self-care, and functioning at the
positive end of the stress-distress continuum would have strong
theoretical and empirical support.
The Impact of Stress on Professional Functioning
How do personal problems and stress impact professional func-
tioning? The stress-distress-impairment-improper behavior contin-
uum proposed by the APA Board of Professional Affairs Advisory
Committee on Colleague Assistance (ACCA; n.d.) provides a
robust model for conceptualizing the progressive downward spiral
that can occur if stress is not effectively managed. In this model,
stress is broadly defined as our body’s reaction to demands that are
placed on it that are generated from either internal (e.g., self-
expectations) or external (e.g., work-related) sources and distress
as the subjective state of reacting to either internal or external
stress that may also be triggered by reactions to past unresolved
events. Impairment refers to an objective change in the psycholo-
gist’s professional functioning that may result in ineffective ser-
vices or cause harm to those with whom we work. Examples of
impairment include being late for appointments or failing to return
phone calls or to complete reports in a timely manner. Improper
behavior refers to professional behaviors that clearly cross ethical
boundaries and constitute professional misconduct. Examples of
improper behavior include sexual or fiscal improprieties with
clients.
A limitation of this model is that it starts at neutral and spirals
down. As we incorporate the tenets of positive psychology and
mindfulness-based principles and practice, we envision a positive
dimension to the continuum and recognize the potential to start at
neutral and spiral up. We propose that self-care supported by
MPPPs can enhance psychologists’ functioning and also serve to
greatly reduce the likelihood of progression through the stages
outlined above. Although we fully appreciate the importance of
acknowledging the potential for negative professional outcomes
and the essential role of colleague assistance programs in prevent-
ing harm to the public, our careers, and ourselves, we hope to also
inspire psychologists to aim for the positive end of the continuum.
Personal Vulnerabilities and Professional Hazards for
Psychologists
Personal vulnerabilities and professional hazards are endemic to
our profession. In our endorsement of a dialectical perspective we
recognize that psychologists’ vulnerabilities may also be strengths
just as the professional hazards may also be benefits. In an intrigu-
ing series on choosing psychotherapy as a career, Farber, Manev-
ich, Metzger, and Saypol (2005) provided an overview of the
common themes that characterize the psychotherapist career path
488 WISE, HERSH, AND GIBSON
linked to the personal narratives of eight prominent professional
psychologists. Factors such as cultural marginalization, psycho-
logical mindedness, and the experience of childhood pain tend to
emerge in the personal histories of psychologists who choose to
become psychotherapists. These factors can be a source of great
strength and compassion but also of vulnerability. As the authors
stated so eloquently, “. . . we all need to remind ourselves of why
we are in this field and how the work has led to unique and
profound, if sometimes elusive, pleasures” (p. 1030).
What are the occupational vulnerabilities for psychologists?
Challenges to professional competence are well documented and
clearly recognized in our field. In a survey of psychologists (Ma-
honey, 1997), one third of respondents reported that they had
experienced anxiety or depression and more than 40% reported
episodes of emotional exhaustion during the previous year. In a
subsequent study (Radeke & Mahoney, 2000), practicing psychol-
ogists reported greater anxiety, depression, and emotional exhaus-
tion than did research psychologists but also a more positive
influence from their work. In a classic article, the majority of
psychotherapists admitted to instances of working when too dis-
tressed to be effective and that nearly all of those surveyed ac-
knowledged that doing so is unethical (Pope, Tabachnick, &
Keith-Spiegel, 1987).
Self-Care Strategies for Psychologists
In recent years there has been a proliferation of self-care articles
and books for psychologists. Many authors agree that it is essential
for psychologists to implement proactive self-care strategies (e.g.,
Baker, 2003;Barnett, Baker, Elman, & Schoener, 2007;Brucato &
Neimeyer, 2009;Norcross & Guy, 2007;Pope & Vasquez, 2005;
Wicks, 2008;Wise, Hersh, & Gibson, 2011;Wise & Gibson,
2012). As we focus on the positive end of the spectrum, specific
self-care content can be drawn from many sources, including
spiritual and religious traditions, secular mindfulness-based ap-
proaches, therapeutic lifestyle changes, and the wealth of wisdom
from our own profession. As a resource for psychologists, we will
briefly describe two broad approaches to self-care and lifestyle
wellness that have provided both a foundation and inspiration for
our thinking. The first is a principle-based, flexible, comprehen-
sive model that was developed explicitly for psychologists (Nor-
cross & Guy, 2007). Their 12 principles draw from broad tradi-
tions of spirituality, mindfulness, and positive psychology in
addition to CBT and physical wellness. The second approach is
based on a comprehensive evidence-based systematic review of
therapeutic lifestyle changes (resulting in the easy-to-remember
acronym TLCs) that were proposed for psychologists to promote
to their clients or patients (Walsh, 2011). This model also explic-
itly incorporates elements of mindfulness, spirituality, and positive
psychology, in addition to specific evidence-based recommenda-
tions for nutrition and exercise that are designed to promote
physical health. The TLCs also incorporate an awareness of our
evolutionary need to be in nature and the negative impact of
overexposure to contexts of hyperreality and media immersion.
Although the TLC approach is intended to be incorporated into our
professional work with clients, research is cited suggesting that,
for example, psychologists who recommend exercise to their cli-
ents are more likely to exercise themselves (McEntee & Halgin,
1996). When asked to comment more broadly on the notion of
reciprocity that is developed in this article, Walsh replied that
In contemplative disciplines there has long been recognition that the
health and maturity of the teacher is essential for cultivating the health
and maturity of students. I assume that therapists will one day recog-
nize the same link between themselves and their patients. (Personal
communication, October 27, 2011)
These comprehensive approaches provide psychologists with
the essential what of self-care (as in what to do). In the next
section, we will outline the mindfulness-based positive principles
and practices (MPPPs) that focus on how these strategies might be
most compassionately and effectively applied to our lives as pro-
fessional psychologists. Along with the four foundational princi-
ples discussed earlier, the MPPPs provide a broad and flexible
blueprint for how psychologists can most effectively, realistically,
and sustainably incorporate self-care strategies and techniques into
our lives.
Mindfulness-Based Positive Principles and Practices
(MPPPs)
The term mindfulness-based positive principles and practices
(MPPPs) is intentionally and explicitly nonclinical. It incorporates
the mindfulness orientation, attitudes, and practices that we rec-
ommend as the foundation and essential component of sustainable
self-care for psychologists. Drawn primarily from mindfulness-
based stress reduction (MBSR; Kabat-Zinn, 1990), acceptance and
commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), and
the positive psychology movement (e.g., Seligman, Steen, Park, &
Peterson, 2005), the MPPPs are consistent with the foundational
principles outlined above in that they minimize the addition of new
self-care commitments and maximize the manageable and inte-
grated transformation of existing ways of thinking, doing, and
being. The approaches on which the MPPPs are primarily based,
share similar (although not entirely overlapping) conceptions of
mindfulness-based acceptance and change processes. MBSR,
ACT, and positive psychology all share an emphasis on intention-
ality and values-driven behavior as motivators and mechanisms for
sustainable lifestyle enhancement. MBSR and ACT differ from
positive psychology, however, in that they promote acceptance of
negative experience whereas positive psychology more explicitly
and directly seeks to promote positive experience. However, taken
together, these approaches are sensitive to our common vulnera-
bilities in that they each view human beings’ locus of suffering
(and the capacity for joy) within the very vicissitudes of being
human rather than within diagnosable psychopathology. It is this
latter point that promotes the principle of reciprocity.Because
client and psychologist often share much in common by way of
sources and manifestations of suffering, psychologists too can
benefit from the very principles and prescribed practices that
they encourage in those who seek their help.
The following sections on mindfulness, ACT, and positive psy-
chology offer theory and research that provide a meaningful
framework for our conceptualization of MPPPs. Although mind-
fulness and ACT are evidence-based treatments in and of them-
selves, we consider them here in their more fundamental embodi-
ment as a set of underlying attitudes that can guide our approach
to self-care and well-being.
489
ETHICS, SELF-CARE, AND WELL-BEING
Mindfulness
What is mindfulness and how is it related to psychologists’
self-care? Mindfulness, at its most basic level, involves “paying
attention in a particular way; on purpose, in the present moment,
and nonjudgmentally” (Kabat-Zinn, 1990). Thus, mindfulness in-
volves the cultivation of intention (i.e., the purposeful and con-
scious choice of where and how we direct our attention moment to
moment and over the long term), a specific type of attention (i.e.,
observing with healthy disengagement one’s moment-to-moment
internal and external experiences), and particular attitudes–those
that relate to nonstriving, acceptance, and curiosity, to name but a
few (Kabat-Zinn, 1990;Shapiro, Carlson, Astin, & Freedman,
2006). The intentional cultivation of mindful awareness helps to
increase gentle awareness of thoughts, emotions, and unhelpful
ways of reacting to stress and stressful situations, in turn reinforc-
ing new and healthier methods and pathways of coping with life’s
daily struggles (Bishop et al., 2004). Thus, mindfulness practice,
when incorporated formally through intentional focus (or medita-
tion) on a regular basis and informally within moments of daily
living, has been shown to confer far-reaching psychological (e.g.,
Hofmann, Sawyer, Witt, & Oh, 2010), neurobiological (e.g., Höl-
zel et al., 2010), and interpersonal benefits (e.g., Carson, Carson,
Gil, & Baucom, 2006). It is important to note that mindfulness
training also facilitates individuals’ increased awareness and valu-
ing of positive and joyful experiences, development of a sense of
interconnectedness with others, and recognition of one’s own and
others’ basic goodness and humanity (e.g., Shapiro & Carlson,
2009).
MBSR is a comprehensive 8-week awareness training program
of securalized Buddhist philosophy and psychology (see Kabat-
Zinn, 1990, for seminal work). MBSR emphasizes formal medi-
tative practices in the form of mindful sitting, walking, yogic
stretching, and loving-kindness meditation along with more infor-
mal practices involving nonjudgmental and purposeful moment-
to-moment awareness of one’s thoughts, emotions, sensations, and
behaviors of daily life (e.g., listening to clients, driving). In this
approach, intentionality is emphasized as a way to help individuals
bring to conscious awareness the qualities they would like to
embody rather than as a means to specific ends (e.g., needing to be
less worried or to reduce blood pressure). It is important that with
respect to the very pragmatic issue of how to build mindfulness
practice into one’s daily repertoire in a cost-effective and time-
efficient manner, Carmody, Baer, Lykins, & Olendzki (2009) have
shown that shorter or less time-intensive MBSR adaptations may
have similar beneficial effects as the original 8-week course. This
finding is quite promising for the perpetually busy and time-
pressured lives professional psychologists often lead and has im-
plications for the incorporation of MPPPs into continuing profes-
sional education and graduate school training (Christopher &
Maris, 2010).
Early research on MBSR for psychologists’ stress and well-
being has yielded encouraging findings, despite some methodolog-
ical limitations. From earlier prepost trials (Shapiro, Schwartz, &
Bonner, 1998) to a more recent controlled, comparative clinical
investigation (Jain et al., 2007), data consistently point to positive
effects of MBSR on clinicians’ perceived stress, psychological
distress, trait depressive and anxious affect, rumination and dis-
traction, empathy, and self- compassion (Jain et al., 2007;Shapiro,
Astin, Biship, & Cordova., 2005;Shapiro, Brown, & Biegel, 2007;
Shapiro, Oman, Thoresen, Plante, & Flinders, 2008;Shapiro,
Schwartz, & Bonner, 1998). Interestingly, an increased sense of
spirituality and relational interconnectedness has also been dem-
onstrated (Shapiro et al., 2008). Thus, the effects of even the most
stressful events in psychologists’ lives may be buffered signifi-
cantly by a gentle, nonjudgmental awareness of the event itself and
the internal experiences that ensue.
One study to date has examined the direct impact of a
mindfulness-based therapy on patients themselves. Grepmair et al.
(2007) found that patients in a psychosomatic hospital whose
therapists were taught Zen meditation were more likely than pa-
tients of the non-Zen trained therapists to benefit in numerous
ways, including self-reported reductions in somatization, obses-
siveness, paranoia, anxiety, anger, and psychoticism, and social
contact. It is notable that this study demonstrated that a variant of
mindfulness meditation can impact patients themselves when ther-
apists train in intentional, nonjudgmental, and present-focused
awareness.
Acceptance and Commitment Therapy (ACT)
Although ACT is broader than mindfulness training proper (see
Hayes et al., 1999), it shares with mindfulness philosophy the
central tenets of acceptance, nonattached and compassionate men-
tal observation of passing phenomena in the mind and body,
intentionality of attention and behavior, and present-focused
awareness. It differs primarily in its more explicit and central focus
on values-driven action. The central aim of ACT is to increase
individuals’ psychological flexibility, which is the capacity to act
based on what one finds most meaningful in life despite the natural
ebb and flow of pain, stress, distress, and even psychopathology
(Hayes et al., 1999). In keeping with a nonstriving attitude (also
emphasized in MBSR), reduction in stress or symptoms is actually
not the main goal nor actively targeted. Rather, entanglement with
(i.e., the attempt to directly control or deny) stress and symptoms
is posited to result in greater dysfunction, and, thus, ACT is known
for its purposeful cultivation of “letting go of the control agenda”
in the service of living a more vital and fulfilling life. When
individuals can intentionally act in accordance with their life
values, despite thoughts, emotions, and overt stressors that popu-
late the mental or physical landscape, psychological flexibility is
strengthened, and life satisfaction increases. ACT has been proven
effective for individuals with general stress-related conditions as
well as for those struggling with depression and anxiety, chronic
pain, substance dependence, and even psychosis (Hayes, Luoma,
Bond, Masuda, & Lillis, 2006).
What is the potential for ACT to help psychologists cultivate
sustainable self-care and well-being? There is preliminary but
promising evidence from a small set of both correlational studies
and clinical trials using samples of workplace employees (Bond &
Bunce, 2000;Bond & Bunce, 2003;Dahl, Wilson, & Nilsson,
2004;Flaxman & Bond, 2010a,2010b) as well substance abuse
counselors (Hayes et al., 2004). Overall, findings from these
studies suggest that a brief on-site ACT workshop can serve as a
potent method for self-care and positive lifestyle integration, im-
proving employees’ mental health; increasing work-related inno-
vation; and reducing burnout, sick leave, and medical clinic utili-
zation.
490 WISE, HERSH, AND GIBSON
Positive Psychology
How do the evidence-based tenets of positive psychology sup-
port our suggested approach to psychologists’ self-care? Research
has consistently shown that activities that make people happy in
small doses, such as shopping, good food, and making money, tend
to have quickly diminishing returns and do not lead to fulfillment
in the long term (Myers, 2000;Ryan & Deci, 2000). Even factors
such as the quality of one’s health (Okun & George, 1984) and
physical attractiveness (Diener, Wolsic, & Fijuta, 1995) account
for only a very small proportion of lasting happiness and well-
being. As Lyubomirsky, Sheldon, and Schkade (2005) strongly
suggested, happiness ultimately can be cultivated and sustained not
through the alteration of internal or external life circumstances but
rather through the intentional undertaking of life-affirming,
happiness-inducing practices and the strengthening of positive
emotionality and positive character traits (Seligman et al., 2005).
Psychologists may avoid many pitfalls and successfully cultivate
sustainable well-being through understanding and putting into
practice a broad-based and increasingly evidence-based frame-
work for positive emotionality as vital to living a healthy and
fulfilling life.
The broaden-and-build theory of positive emotions (Fredrick-
son, 1998,2001) posits that positive emotions can broaden our
cognitive, attentional, and behavioral repertoires. When repeated,
such a broadened state and perspective can facilitate the cultivation
of personal resources and traits of resilience for sustainable well-
being (Cohn & Fredrickson, 2009;Fredrickson, 1998). In a virtu-
ous (positive) cycle, newly cultivated resources and capacities for
coping can then increase a growing trait-like inclination toward
positive emotionality, thus, broadening once again one’s aware-
ness of new opportunities for positive emotion and resource cul-
tivation (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009).
As the Vietnamese meditation teacher and peace activist, Thich
Nhat Hahn, has aptly suggested, “sometimes your joy can be the
source of your smile, but sometimes your smile can be the source
of your joy.” Research has increasingly supported this wisdom and
demonstrated that when intentionally induced, positivity can
broaden attention, cognition, and creativity; enhance feelings of
closeness with and trust in others (e.g., Dunn & Schweitzer, 2005;
Waugh & Fredrickson, 2006); buffer stress and negative emotional
reactivity; and result in new and adaptive thinking, feeling, and
action (Garland & Howard, 2009). Supporting such basic research
findings, one study (Fredrickson, Cohn, Coffey, Pek, & Finkel,
2008) impressively demonstrated that through a 7-week loving-
kindness meditation workshop (derived from the mindfulness
meditation tradition) that was designed to help participants to
intentionally focus the mind and body on wishing others and the
self well, a range of positive emotional experiences (e.g., gratitude,
hope, contentment, joy) were cultivated over time and increased
with greater meditative practice. Personal resources and resilience
traits, reduced illness symptomatology, improved relations with
others, and mindfulness became increasingly evident and subse-
quently predicted greater life satisfaction and reduced depressive
symptomatology (Cohn & Fredrickson, 2010). Of particular rele-
vance to our emphasis on building sustainable self-care practice
and well-being for psychologists, the range of benefits from learn-
ing loving-kindness meditation was sustained one year later (Cohn
& Fredrickson, 2010).
Gratitude practice has also received increasing attention as a
method of cultivating greater well-being. In fact, research suggests
that people who express gratitude on a regular basis have better
physical health, optimism, progress toward goals, well-being, and
help others more (Emmons & Crumpler, 2000). Gratitude practices
might include keeping a gratitude journal on a daily basis, regu-
larly updating a list of people for whom one is grateful and
reaching out to those who have positively impacted one’s life, and
acknowledging the personal strengths and qualities one possesses.
Practicing optimistic thinking (Seligman, 1998) as well as identi-
fying, appreciating, and building on one’s signature strengths and
virtues has also been shown to improve one’s quality of life and
sense of well-being and can act as an antidepressant and stress
resilience factor (Seligman et al., 2005). It is interesting to note
that the “heart” qualities of hope, gratitude, and love, for example,
have been more strongly associated with life fulfillment than
character strengths that suggest more cerebral leanings (e.g., curi-
osity, love of learning; Park, Peterson, & Seligman, 2004). This
factor may make the practice of gratitude particularly meaningful
for psychologists in their role as psychotherapists with its unique
and complex blend of intellectual conceptualization and human
relatedness.
What Are the Potential Benefits of MPPPs for
Psychologists?
First, through the intentional cultivation of nonjudgmental con-
tact with the present moment (i.e., mindful awareness), psycholo-
gists can learn to be more comfortable with difficult emotions in
their role as healers and helpers. Given psychologists’ personal
histories and motivations for entering the field of psychology
(Farber et al., 2005), there is a clear need for increased self-
compassion, the awareness of countertransference reactions, and
capacity to attune to clients’ emotional lives without overidentifi-
cation. Mindfulness-based practices might, for example, serve to
simultaneously enhance self-compassion, compassion for clients
and loved ones, and decrease ruminative tendencies about difficult
clients and one’s personal limitations (e.g., Siegel, 2010). Such
enhanced capacities would improve psychologists’ quality of life,
help “cushion” more difficult and stressful moments, and provide
more space to experience joy and sense of purpose in life. Second,
by identifying and repeatedly reaffirming core life values, psychol-
ogists can intentionally refocus their efforts on what is most
meaningful, rather than becoming sidetracked by avoidance of
what is stressful or fusing with unhelpful thoughts about one’s
professional incompetence—thereby demonstrating enhanced psy-
chological flexibility. These principles and practices could pro-
mote positive self-care-oriented activities—such as exercise, med-
itation, spending time with close friends and family, being in
nature—becoming woven into the fabric of psychologists’ daily
life because they would align with life-affirming and flourishing-
focused attitudes. Incorporation of these positive psychological
principles supports commitment to a meaningful and fulfilling life
and promotes engagement in happiness-producing, stress buffer-
ing, and well-being enhancing practices, such as gratitude expres-
sion and loving-kindness meditation. These practices and medita-
tions can be done as brief wellness-enhancing, self-care exercises
that can be seamlessly integrated into daily life. As an example, on
the commute home, a psychologist could repeat silently, with a
491
ETHICS, SELF-CARE, AND WELL-BEING
sense of unconditional warmth, “May [I, my family, my clients]
experience safety, happiness, strength, and ease of mind.” Given
that loving-kindness practice has been shown to have long-term
and varied benefits, psychologists would have evidence-based
support to integrate this practice into their daily lives. The benefits
of practicing gratitude (even briefly) on a regular basis have
already been discussed. If such practices are integrated into daily
life, psychologists may begin to feel as though self-care, well-
being, and even happiness do not have to be targeted as goals to be
attained but rather simply as how a fulfilling and meaningful life
is to be lived.
A Vision for the Future
We see significant potential for the incorporation of these prin-
ciples and practices into graduate training programs, professional
developmental modules during clinical internship, and a wide
range of potential training opportunities for early career and ex-
perienced clinicians. We can envision it becoming common prac-
tice for psychologists to intentionally engage in the practices
suggested by this research and to encourage their use by clients. In
addition, we see important potential policy implications related to
how continuing professional education and development is con-
ceptualized for psychologists. If incorporated into formal continu-
ing education offerings, psychologists could simultaneously work
toward licensure renewal while experientially learning evidence-
based and practical approaches for more effectively managing
stress, cultivating well-being, and potentially enhancing the
therapist–client relationship and client outcomes. The possibilities
for psychological and interpersonal transformation continue to be
documented, and it may now be time for those of us who devote
our days to helping others to transform our own lives toward
mindful awareness and positive sustainable well-being. Document-
ing the benefits of these approaches for psychologists’ functioning
is a promising focus for future research.
Finally, we believe that sustainable psychologist self-care must
build from (and repeatedly return to) an abiding acknowledgment
of being truly human. When psychologists more readily realize the
false demarcations between themselves and their clients, self-care
becomes not only an ethical imperative but a humanistic one as
well. It stands to reason that when mindful awareness, positive
emotion, or personal strengths are intentionally cultivated, they
can more easily be integrated and sustained. Keeping within con-
scious awareness that which is easily forgotten may be one of the
most vital foundational practices to which psychologists can as-
pire. Sustainable self-care and enhanced well-being, however, are
not free. But we must ask ourselves what comes at a higher cost:
maintaining a status quo that promotes a sense of mere survival or
mindfully exerting the effort, creativity, and time it takes to prac-
tice the art and science of self-care in the service of flourishing and
living a life of sustainable well-being. Finally, in a return to where
we started, “if not now, when?”
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Received December 28, 2011
Revision received June 15, 2012
Accepted June 20, 2012
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494 WISE, HERSH, AND GIBSON
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Objective: Subjective well-being is a crucial variable for mental health practitioners. This study examines the influence of therapists’ attachment dimensions and self-reported reflective functioning on their perceived well-being. Further, it examines if reflective functioning mediates the association between attachment insecurity and well-being. Method: A total of 416 experienced psychotherapists were enrolled in this cross-sectional study, and completed self-report measures of attachment insecurity, reflective functioning, and well-being. We tested the hypothesized mediation model with path analysis that examined indirect effects. Results: Both attachment anxiety and avoidance dimensions had a significant negative association with perceived well-being with small to medium effects. “Certainty” in reflective functioning had a small positive effect on therapist well-being. Reflective functioning mediated the association between insecure attachment dimensions and well-being, suggesting that therapist's lower ability to mentalize may partially account for the effects of higher attachment insecurity on lower well-being. Conclusion: The well-being of psychotherapists with greater insecure attachment may deserve special attention, and therapists’ mentalizing capacities may be targeted by researchers and trainers as a core ability to be cultivated in order to preserve therapists’ professional and personal resources.
Thesis
Child welfare workers are faced with suffering on a daily basis. Workers report experiencing empathetic distress (also known as compassion fatigue) and many feel discouraged from showing self-compassion or compassion toward others. However, the literature on compassion suggests that self-compassion and compassion for others builds resiliency, improves job satisfaction and increases engagement. Workers who support themselves with self-compassion may be less likely to experience burnout and more willing to create inclusive and compassionate environments. This study was conducted in two phases. The goals of the Phase 1 mixed-method, cross sectional study were to (1) assess the level of self-compassion and compassion for others experienced by child welfare workers and (2) to identify barriers and facilitators to organizational compassion. A quantitative survey was administered to 100 employees in a child welfare agency in Ontario. Twenty employees (20%) completed the online survey. Two leaders were interviewed about compassion in their organization. Data collection was discontinued because of the COVID-19 pandemic. Phase 1 findings show a low-level of organizational trust reported by workers and lower levels of self-compassion and compassion for and from others compared to a sample of US Child Welfare workers. Qualitative findings revealed barriers to compassion including: a culture of toughness, role siloing, layoffs and lack of trust among workers, fear, and a crisis driven organizational environment subject to persistent system changes. Facilitators included: worker interpretation of the reason for the behaviour (trauma informed practice), curiosity, listening to the voices of clients, flexibility, risk-taking, mindfulness and supervisor support. 3 Phase 2 of this study involved a comparative content analysis of the 1990 Child and Family Services Act (CFSA) and the 2017 Child and Youth Family Services Act (CYFSA) alongside the 2016 Ontario Child Protection Standards. The goal of this Phase 2 portion was to investigate how compassion is framed discursively and institutionally within this organization. Overall, the results showed an absence of language pertaining to the concept of compassion across all texts. It also showed an increased emphasis on control and surveillance over the work of CASs in the CYFSA and accompanying Standards as compared to the CFSA. Additionally, the CYFSA showed an increased focus on the rights of children, as well as relationships with parents, which are promising indicators of compassion. Overall however, the language of the legislation complicates the possibilities for emphasizing compassion, thereby increasing the potential for more dehumanized forms of intervention. The study concludes with recommendations for increasing compassion inside child welfare systems. 4 ACKNOWLEDGEMENTS
Article
Background Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work‐related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience‐promoting training programmes. Objectives To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists). Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results. Selection criteria Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post‐traumatic growth versus no intervention, wait‐list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well‐being or quality of life. Secondary outcomes were resilience factors. Data collection and analysis Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post‐test only). Main results We included 44 RCTs (high‐income countries: 36). Thirty‐nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face‐to‐face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive‐behavioural therapy) versus unspecific comparators (e.g. wait‐list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post‐intervention, very‐low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD −0.29, 95% CI −0.50 to −0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD −0.61, 95% CI −1.07 to −0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD −0.06, 95% CI −0.35 to 0.23; 5 studies, 231 participants; very‐low certainty evidence) or well‐being or quality of life (SMD 0.14, 95% CI −0.01 to 0.30; 13 studies, 1494 participants; very‐low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very‐low certainty evidence). Authors' conclusions For healthcare professionals, there is very‐low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post‐intervention. The paucity of medium‐ or long‐term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high‐quality replications and improved study designs.
Thesis
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La Rumiación es un estilo desadaptativo de respuesta en el que la persona se concentra en los propios pensamientos, emociones y síntomas de manera repetitiva y pasiva. Esto se encuentra asociado a los niveles de Afecto Negativo y Afecto Positivo del individuo. Este estudio tuvo como objetivo describir y analizar la relación entre el Afecto Positivo, Afecto Negativo y la Rumiación teniendo en cuenta la variable género en el contexto laboral. Para ello se obtuvo una muestra de 299 profesionales, 158 hombres ingenieros civiles (52,8%) y 141 mujeres psicólogas (47,2%), siendo la edad promedio 35,02 años. Fueron utilizadas la Escala de Afectividad Positiva y Negativa (PANAS) de Watson, Clark y Tellegen, y la Escala de Respuestas Rumiativas (RRS) de Nolen-Hoeksema y Morrow. Los datos obtenidos sugieren que existe una diferencia significativa entre los hombres ingenieros y las mujeres psicólogas en Afecto Positivo, a favor de los primeros. No obstante, se halló que una de las dimensiones de la Rumiación presentó niveles mayores en las mujeres. Asimismo en este trabajo se analiza la relación entre Afecto Negativo, Afecto Positivo y Rumiación, que confirman parcialmente lo hallado en la bibliografía previa. Por último se discute las posibles implicancias de estos resultados.
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There is general consensus that self-rated health is the strongest predictor of subjective well-being during adulthood. What is not understood is the reason for the consistent relationship between these two variables. Other literature suggests that self-report health ratings are a function of both objective physical health status and neuroticism. This study examines the interrelationships among neuroticism, physician-rated health, self-rated health and subjective well-being concurrently and prospectively. Relationships are compared across gender, indicators of subjective well-being and times of measurement. The sample includes 243 men and 225 women in the cross-sectional analyses and 185 men and 165 women in the longitudinal analyses. As predicted, the results indicate that: 1.(1) self-rated health is significantly correlated with neuroticism, physician-rated health and subjective well-being;2.(2) neuroticism is significantly related to subjective well-being;3.(3) physician-rated health is weakly correlated with subjective well-being; and4.(4) partialling out neuroticism reduces the association between self-rated health and subjective well-being more than partialling out physician-rated health. Unexpectedly, neuroticism is significantly related to changes in subjective well-being.Future studies of the determinants of subjective well-being should include measures of neuroticism and physician-rated health.
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For professional psychologists there is a strong link between self-care and competence. Principle A of the 2002 APA Ethics Code reminds us that "Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work". This chapter provides a broad overview of our ethical responsibilities and a framework for effective decision making in the areas of self-care and competence. Using the perspective of professional development, policies and research related to self-care and competence in graduate training and professional practice are reviewed and discussed. In addition, the implications of several lines of relevant research will be considered including challenges to engaging in effective self-assessment and self-care and the positive impact on therapist well-being and client outcomes of mindfulness training. Professional vignettes and recommendations for best practices in professional practice and graduate training are described.
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Chapter
This chapter discusses the approach of mindfulness-based relationship enhancement (MBRE) in couples. Enduring human partnerships inevitably entail adjustment to a course of stressful events and situations, both minor and major. Mindfulness meditation group interventions are efficacious in helping individuals to cope more effectively with stress in a variety of nonclinical and clinical populations. The theoretical basis for applying mindfulness to boost partners' stress coping skills and enhance their relationships is based on at least four salient processes: (1) The act of being mindful-that is, incorporating all experiences, whether enjoyable or difficult, into nonjudgmental presence of mind; (2) The acceptance of one's experience as they are, thereby increasing the compassion and empathy toward others; (3) promoting the relaxation response that results in changes that are the mirror opposite of stress-induced hyperarousal, and subjectively is often experienced as feelings of calm, clarity, and well-being; and (4) self-broadening, leading to attitudinal transformations that are expressed in terms of a greater sense of trust, love for others, and connectedness with a greater "whole." This shows that relationship satisfaction between couple increases through mutual engagement in exciting, self-expanding activities including those leading to the discovery of linkages, wisdom, and their position in the universe.
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Gratitude is an emotional state and an attitude toward life that is a source of human strength in enhancing one's personal and relational well-being. In this article, we first explore the theological origins of gratitude as a virtue to be cultivated in the major monotheistic traditions of Judaism, Christianity, and Islam. Each tradition emphasizes the development of gratitude as a path to a good life, and prescribes approaches for practicing. Gratitude is explored further in the context of psychological theory and research. Empirical research linking gratitude with well-being and goal attainment is presented and discussed. Finally, future research questions and a tentative research agenda are presented.