self-care | The Professional Counselor

Self-Care Through Self-Compassion: A Balm for Burnout

Apr 18, 2017 | Volume 7 - Issue 3

Susannah C. Coaston

Counselors are routinely exposed to painful situations and overwhelming emotions that can, over time, result in burnout. Although counselors routinely promote self-care, many struggle to practice such wellness regularly, putting themselves at increased risk for burning out. Compassion is essential to the helper’s role, as it allows counselors to develop the therapeutic relationship vital for change; however, it is often difficult to direct this compassion inward. Developing an attitude of self-compassion and mindfulness in the context of a self-care plan can create space for an authentic, kind response to the challenges inherent in counseling. This article expands beyond the aspirational aspects of self-compassion and suggests a variety of practices for the mind, body, and spirit, with the intention of supporting the development of an individualized self-care plan for counselors.

Keywords: self-care, self-compassion, burnout, mindfulness, wellness

Wellness, prevention, and human development compose the core of a counselor’s professional identity (Mellin, Hunt, & Nichols, 2011). This fundamental grounding is emphasized within the American Counseling Association’s (ACA) Code of Ethics (ACA, 2014), as well as by the Council for Accreditation of Counseling & Related Education Programs (CACREP; 2016). To fulfill their role in the change process, counselors depend heavily upon compassion, a key component of the therapeutic relationship that—paradoxically—counselors may seldom apply to themselves (Patsiopoulos & Buchanan, 2011). Whereas compassion means being with others in their suffering (Pollack, Pedulla, & Siegel, 2014), self-compassion can be understood as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness” (Neff, 2003, p. 87). Higher levels of self-compassion can serve as a buffer against burnout (Barnard & Curry, 2011). Therefore, cultivating an attitude of self-compassion may assist counselors in employing self-care practices to refresh, rejuvenate, and recharge their bodies, minds, and souls. The purpose of this manuscript is to reimagine self-care as regular acts of self-compassion that benefit both clients and counselors.

Self-Compassion

Self-compassion, a construct from Buddhist thought, consists of self-kindness, common humanity, and mindfulness, and is characterized by gentleness with oneself when faced with a perceived sense of inadequacy or failure (Neff, 2003). Self-compassion is not based on an evaluation of the self; self-compassion becomes the path to positively relating to oneself (Neff & Costigan, 2014). The concept of self-compassion is consistent with the idea of self-acceptance in the humanistic tradition (Neff, 2003). Carl Rogers (1961) described a successful outcome of psychotherapy as an increase in positive attitudes toward self: “The client not only accepts himself . . . he actually comes to like himself. This is not a bragging or self-assertive liking; it is a rather quiet pleasure in being one’s self” (p. 87). The practice of self-compassion calls for a mindful awareness of emotions, and painful emotions are met with a sense of understanding, connection to our common humanity, and self-kindness (Neff, 2003). Neff and Costigan (2014) described self-compassion’s relationship with pain thusly: “Self-compassion does not avoid pain, but rather embraces it with kindness and goodwill that is rooted in the experience of being fully human” (p. 114). Self-compassion practices have been found to improve psychological functioning in both clinical and non-clinical settings (Neff, Kirkpatrick, & Rude, 2007; Schanche, Stiles, McCullough, Svartberg, & Nielsen, 2011).

Mindfulness is one of the core components of self-compassion and is critical for the awareness of suffering that precedes compassion (Germer & Neff, 2015). Mindfulness is the focusing on the awareness of pain in the present moment, and self-compassion becomes the act of taking that awareness and encouraging kindness toward oneself. The common humanity component of self-compassion becomes one of acknowledgment that, as humans, we are imperfect and make mistakes; recognizing our flawed condition allows for a broader perspective toward our difficulties (Neff, 2003). Adopting such a view of pain reduces the chance of over-identification or getting so wrapped up in one’s emotions that they become exaggerated (Neff & Costigan, 2014). When an individual can recognize pain as a universal occurrence, such a viewpoint then fosters a sense of connection with others who have felt suffering. Pain becomes an uncomfortable but acknowledged part of the human condition. When practicing self-compassion, the self-directed kindness is not done to change the circumstance of suffering, but done because there is suffering. The practitioner asks “What do I need now?” The individual then acts accordingly to provide comfort when experiencing the pain of inadequacy or failure (Germer & Neff, 2015). Learning self-compassion becomes a gift for both clients and the practitioner (Barnett, Baker, Elman, & Schoener, 2007). Making time for one’s self is one way counselors can practice self-care (Patsiopoulos & Buchana, 2011). That self-acceptance can prove vital for counselors, whose work often puts them at a risk for burnout (Yager & Tovar-Blank, 2007).

Counselor Burnout

Burnout is a multidimensional experience consisting of exhaustion, cynicism, and reduced professional efficacy that can result from dissatisfaction with the organizational context of the job position (Maslach, Schaufeli, & Leiter, 2001). Burnout can affect individuals in a variety of ways, with anxiety, irritability, fatigue, withdrawal, and demoralization as major examples (Schaufeli & Enzmann, 1998). Burnout can affect individuals at any point in their career and can hamper productivity and creativity, resulting in a reduction of compassion toward themselves and clients (Grosch & Olsen, 1994). “It is when counseling seems to have little effect that counselors reach despair because their raison d’être for choosing this work—to make a difference in human life—is threatened” (Skovholt, Grier, & Hanson, 2001, p. 171). Caring for others and caring for oneself becomes a difficult balance to achieve for both new and seasoned counselors alike. Carl Rogers (1980) wrote, “I have always been better at caring for and looking after others than I have in caring for myself. But in these later years, I made progress” (p. 80). Self-compassion can serve as a protective factor against such potentially debilitating effects of work-related burnout.

Historically, researchers examined the causes of burnout relating to demographic, personality, or attitudinal differences between individuals (Maslach et al., 2001). Today, burnout is viewed from an organizational standpoint and is concerned with the relationship, or fit, between the person and his or her environment, wherein mismatches can result in burnout over time (Maslach, Leiter, & Jackson, 2012). An individual’s perceptions have a reciprocal relationship with the work environment; how counselors make meaning of their work impacts their satisfaction, commitment, and performance in the workplace (Lindholm, 2003). Counselors experiencing work-related stress and burnout will construct meaning differently and require a tailored self-care plan that reflects their individual assessment of their own fit within their work environment.

Counselor Self-Care

Self-care can be defined as an activity to “refill and refuel oneself in healthy ways” (Gentry, 2002, p. 48). Self-care is vital if we are to remain effective in our role and avoid burnout; however, many counselors do not regularly implement the techniques they recommend to clients in their own lives (O’Halloran & Linton, 2000; Skovholt et al., 2001). Although self-care is widely promoted within the counseling literature, this author contends that inherent in many self-care plans and workplace improvement efforts is the idea that overwhelming work-related stress reflects an inadequacy of the individual. The message in the literature often reflects the view that a counselor’s distress hinges upon inadequate coping resources, poor health practices, or other kinds of personal failing, such as lacking assertiveness or not taking enough time off from work (Bradley, Whisenhunt, Adamson, & Kress, 2013; Killian, 2008; O’Halloran & Linton, 2000). As a result, self-care plans tend to take on the air of a New Year’s resolution, a strategy to get better. This narrow focus reflects the historical view of burnout that focused primarily on its individual dimension, without taking into consideration the organizational, interpersonal, or societal perspectives (Schaufeli & Enzmann, 1998). When self-care plans are written like self-improvement plans, the opportunities for criticism and judgment abound, particularly for new counselors who struggle with anxiety and self-doubt (Skovholt, 2012). When counselors are suffering, experiencing symptoms of burnout, struggling to maintain healthy professional boundaries (i.e., under- or over-involvement), or feeling as though they are not caring for themselves effectively, shame may cause them to be less likely to seek assistance (Graff, 2008). Some counselors may fear negative repercussions as a result of disclosure, such as being perceived as impaired or having professional competency problems (Rust, Raskin, & Hill, 2013).

Self-care is an ethical imperative (ACA, 2014), because utilizing self-care strategies reduces the likelihood of impairment (ACA, 2010). Issues in a counselor’s personal life, burnout in the workplace, mental or physical disability, or substance abuse can result in impairment (ACA, 2010). Sadly, in a survey completed in 2004, nearly two-thirds of participants knew a counselor that they would identify as impaired (ACA, 2010). Counselors who better manage their self-care needs are more likely to set appropriate boundaries with clients and less likely to use clients to meet their own personal or professional needs (Nielsen, 1988). Self-care education has been integrated into the accreditation standards for counselor training (CACREP, 2016), and there are multiple articles discussing how to incorporate the value of wellness and self-care into counselor education programs (Witmer & Young, 1996; Yager & Tovar-Blank, 2007). For counselor educators and supervisors, monitoring counselors-in-training for possible impairment is an important part of the responsibility of gatekeeping (Frame & Stevens-Smith, 1995). However, despite this attention, both students and practicing professional counselors still struggle to implement self-care (Skovholt et al., 2001; E. Thompson, Frick, & Trice-Black, 2011).

Bradley and colleagues (2013) suggested that many of the self-care suggestions in the literature are too general, focusing mainly on general health practices, such as eating healthily and getting enough sleep, or professional recommendations regarding seeking support from colleagues. A case can be made that a counselor would be better served by employing an overall approach to efforts that are based in a self-compassionate mindset. Therefore, actively seeking awareness of one’s own signs and symptoms that indicate suffering can not only help counselors recognize burnout, it also can provide clues toward the first step in soothing.

Mindfulness represents one possible means of increasing such awareness. Mindfulness allows the practitioner to be present in the moment non-judgmentally (Kabat-Zinn, 1994). To practice self-compassion, a counselor needs to be willing to attend to feelings of discomfort, pain, or suffering and acknowledge the experience without self-recrimination (Germer & Neff, 2015). Consider the experience of having a regular client stop attending sessions and returning calls or abruptly discontinuing services. Although common, the ambiguous loss of a connection with a client can be a source of stress and pain (Skovholt et al., 2001). It also can provide an opportunity. Covey (2010) shared the following quote that is often misattributed to Viktor Frankl: “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom” (p. VI). The space Covey describes is our opportunity to be mindful of the stimulus and choose to offer ourselves compassion in response. Choosing to deny, suppress, or distract to avoid these feelings may cause the counselor to miss the trigger to practice self-care. When such feelings are recognized, the counselor may act compassionately toward himself or herself by normalizing or validating the experience. Within self-compassion, the concept of common humanity becomes crucial to precluding the often-automatic tendency to become self-critical for experiencing discomfort (Neff, 2003). Thoughts such as, “I shouldn’t feel this way,” “Just snap out of it; it’s not so bad,” or “What’s wrong with me?” invalidate the sufferer and may cause the counselor to feel as though self-care is an act of indulgence rather than an essential, self-directed gift of kindness. Expressing kindness through self-care acknowledges that counseling can be both difficult and rewarding, a duality representative of the human condition.

When counselors choose to practice self-care, they enhance themselves and their practice. One participant in a narrative inquiry on self-compassion in counseling stated: “What’s so important about self-compassion? Three words: Avoidance of burnout” (Patsiopoulos & Buchanan, 2011, p. 305). Another participant noted, “When we come from a self-compassionate place, self-care is no longer about these sporadic one-time events that you do when you feel burned out and exhausted. Self-care is something you can do all the time” (Patsiopoulos & Buchanan, 2011, p. 305). The consequence of our job as counselors is working compassionately with suffering, and in doing so we suffer (Figley, 2002).

For someone to develop genuine compassion toward others, first he or she must have a basis upon which to cultivate compassion, and that basis is the ability to connect to one’s own feelings and to care for one’s own welfare. . . . Caring for others requires caring for oneself. (Germer & Neff, 2015, p. 48) Self-care, then, is a vital part of a counselor’s responsibilities to clients and to one’s self.

It is important to remember that counseling can be emotionally demanding for counselors in different ways (O’Halloran & Linton, 2000). Self-compassion encourages remembering the shared human experience (Neff, 2003), as the experience of being a professional counselor can be quite isolating, especially for those working in more independent environments (e.g., school counselors, private practitioners; Freadling & Foss-Kelly, 2014; Matthes, 1992). Using mindfulness, counselors can maintain an objective stance that can allow the counselor to view one’s work circumstances with a non-judgmental lens (Newsome, Waldo, & Gruszka, 2012), then act kindly to intervene with a self-care practice that is revitalizing to mind, body, and spirit. Using self-compassion tenets as a guide, self-care plans can be created that are authentic and kind, connect us to the human experience, and reflect a balanced state of self-awareness.

Creating a Self-Compassion–Infused Self-Care Plan

In wellness counseling, optimal functioning of the mind, body, and spirit is the goal for holistic wellness (Myers, Sweeney, & Witmer, 2001). The physical dimension is the most common focus for wellness intervention (Carney, 2007); however, this is quite limiting in a profession that is often sedentary, with long hours and pressure to meet productivity demands (Franco, 2016; Freadling & Foss-Kelly, 2014; Ohrt, Prosek, Ener, & Lindo, 2015). Maintaining one’s health is important but may not be enough to assuage the emotional demands of a high-touch profession in which a strong professional relationship is combined with the often-conflicting pressures of reimbursement; short-term, diagnosis-focused treatment; and behaviorally based outcomes associated with managed care (Cushman & Gilford, 2000; Freadling & Foss-Kelly, 2014). Developing a collaborative treatment plan is a common practice in counseling; it allows the counselor and the client to determine the possible direction and outcomes for their work together (Kress & Paylo, 2015). In the best case, this plan is individualized, specific, and open to revision when necessary. A good self-care plan can follow the same formula.

What follows are specific suggestions regarding self-care practices that stretch beyond the “should,” the “ought to,” and the New Year’s resolution language. When reading the interventions, consider the question Linder, Miller, and Johnson (2000) suggested for clients when encouraging self-care: “How do you reassure yourself?” (p. 4). The suggestions are organized into mind, body, and spirit; however, these are artificial divisions and some interventions may satisfy in multiple ways.

Interventions for the Mind

Mindfulness is a component of self-compassion, but it can also be used intentionally as a regular practice for self-care. Mindfulness can be described as a dispositional trait, a state of being and a practice (Brown, Ryan, & Creswell, 2007). The use of mindfulness has been integrated into many facets of counseling practice (I. Thompson, Amatea, & Thompson, 2014). For those attracted to the practice of mindfulness for self-care, non-judgmental awareness can be integrated as a practice (e.g., a set time for engagement in a particular mindfulness exercise) or as a way of being during particular activities within the day. Exercises such as mindful eating, maintaining sensory awareness while washing dishes, or mindful walking can be helpful for those who are looking for brief, everyday opportunities for self-care. Researchers I. Thompson and colleagues (2014) found that higher levels of mindfulness corresponded with lower levels of burnout. Mindfulness has been suggested as a beneficial way to teach self-care in counselor training (Christopher, Christopher, Dunnagan, & Schure, 2006), and also as a way to reduce stress and increase self-compassion in students training to be in helping professions (Newsome et al., 2012). For any number of reasons, not all counselors may find benefit in mindfulness practices; therefore, some may choose methods of self-care that are more mentally invigorating.

Intellectual stimulation in any endeavor is important to maintain engagement, interest, and enjoyment, but such motivation can be particularly helpful when a work position contains routine, mundane, or downright boring tasks. To create a stimulating work life, seasoned professionals find active ways to continue their professional development, which can decrease the boredom that can lead to burnout (Skovholt et al., 2001). Activities for growth and development can include learning something new within counseling or outside the profession, such as learning a new language, or how to make sushi, write code, or play a strategy game such as the ancient board game, Go.

The role of a counselor involves exposure to circumstances of human suffering, painful emotions, and heartbreaking situations, which increases the risk of burnout due to absorption of the clients’ pain (Ruysschaert, 2009). Finding a way to keep and maintain positive memories, cards and notes, compliments or successes—what this author terms warm and fuzzies—either personally or professionally, in a box, folder, jar, or bulletin board, can be a helpful response. Bradley and colleagues (2013) suggested tracking small changes made by clients when discouraged and sharing the progress with co-workers.

Writing can be a powerful intervention in a counseling setting and can benefit both mental and physical health (Pennebaker & Seagal, 1999; Riordan, 1996). Counselors can use the medium of writing in a multitude of ways. Whether through journaling, narrative, poetry, musical lyrics, or letters, the act of writing can reduce emotional inhibition (Connolly Baker & Mazza, 2004). Creative writing can be used to access the healing benefits of writing without worry about form or audience (Warren, Morgan, Morris, & Morris, 2010).

Warren et al.’s (2010) The Writing Workout is a way to express, validate, and externalize painful emotions. This wellness approach illustrates how creative writing for self-care can cultivate compassion. Narrative writing strategies can allow the writer to change the outcome of a lived experience or reframe a life experience (Connelly Baker & Mazza, 2004). Creating a narrative of an event can help the storyteller organize details and events, reflect and process thoughts and feelings, and derive meaning from experiences (Pennebaker & Seagal, 1999). A creative, mindful writing intervention could be used to examine a clinical situation that may not have gone as the counselor had hoped, or to creatively explore life lessons derived from a clinical encounter. For some clinicians, writing gives voice to emotions too raw to easily speak aloud (Wright, 2003).

Traditional journaling can allow for self-reflection, increased self-awareness, and growth (Lent, 2009; Utley & Garza, 2011). Journal writing can be inherently self-compassionate. Linder et al. (2000) discussed the use of a non-judgmental journaling practice in which there are no wrong words and writers are encouraged to use random sentences and words that do not make sense. Through almost nonsensical form, journaling offers a sense of safety and freedom, while creating a trusting relationship with the journal. Linder et al. (2000) stated, “Journaling finds the meaning in meaninglessness and negates the emptiness through creating writing from the heart. It is an outlet to tell the truth without being judged” (p. 7).

Beyond the traditional journal, counselors may find alternative ways to use journaling for emotional expression, such as use of bullet journaling or a personal blog online. Bullet journaling uses a rapid-logging approach, or a visual code, to represents tasks, events, and notes in a physical notebook (Bullet Journal, 2017). Keeping a bullet journal is a clever way of managing multiple arenas of one’s life in a single place, and the events and notes categories can be particularly helpful in the practice of journaling for self-care. Events are to be written down briefly and objectively despite the degree of emotional content they carry (Bullet Journal, 2017), offering an opportunity to practice the non-reactive skill of mindfulness (Kabat-Zinn, 1994). Once an event has been entered, the counselor can respond mindfully to it by writing at length on the following page. The notes category for bullet journaling consists of ideas, thoughts, or observations (Bullet Journal, 2017), which could include inspirational quotes, eureka moments, or other insights worth reviewing at a later date. The author can use signifiers (i.e., symbols) to create a legend to provide additional context for an event, note, or task. The bullet journal approach for self-expression exemplifies a creative twist on an old concept to better fit the preferences of the writer. Similarly, scrapbook journaling can be used to accommodate the types of expressive media that resonate with the counselor’s personal style or interests (Bradley et al., 2013). Counselors can use photos, poems, song lyrics, and quotes to reflect their emotional state, and then reflect on the emotional patterns or themes that arise. For counselors who prefer to share their thoughts on the Internet, an online blog can be a cost-effective, accessible medium to express oneself emotionally and share thoughts, feelings, and experiences with others (Lent, 2009). Counselors should consider the risks associated with the use of the Internet and maintenance of confidentiality in an online medium in accordance with the ACA Code of Ethics (2014).

Finally, a simple self-care intervention can involve writing oneself a permission slip or prescription for something. This could be the permission to be imperfect, to take a mental health day, or to run through a sprinkler on a hot day. A writing assignment of this sort expresses kindness in providing the very thing that is needed for an emotional recharge. In some cases, this may involve taking a quiet moment to allow one’s mind to wander. This can occur during a warm bath or shower at the end of the day or while savoring a warm cup of coffee or tea in the afternoon. Although mind-wandering can be a threat to effectiveness and productivity when it occurs at inopportune times, taking time for mind-wandering can relieve boredom, stimulate creative thoughts, and facilitate future planning (Smallwood & Schooler, 2015).

Interventions for the Body

Many self-care plans begin and end with a strong concentration on physical self-care, typically involving making nutritional changes and increasing physical activity (Bradley et al., 2013; E. Thompson et al., 2011). These therapeutic lifestyle changes (TLCs) can have a huge impact on health and well-being (Walsh, 2011). Although the mental health benefits of these types of changes are well documented (Walsh, 2011), a myopic focus on physiological wellness may be limiting, and self-care should include a broader range of ways to cope (E. Thompson et al., 2011). For individuals wishing to focus specifically on such changes, using the imagery of caring for oneself as one does a plant may increase self-awareness of bodily self-care needs (Bradley et al., 2013). Considering one’s needs in this metaphorical way may help counselors increase their own self-compassion by considering their unique needs and the changes they are ready and willing to make. A counselor may indicate they require shade from the sun, which could represent reducing over-stimulating environments; good spacing from other plants, indicating healthy boundaries or alone time; and water and nutrients, which may remind the counselor to keep a pitcher of water on the desk and a bag of almonds in a drawer. Externalizing in this way can be particularly helpful when learning self-compassion because often counselors find it easier to care for others than themselves (Patsiopoulos & Buchanan, 2011).

Although exercise has clear mental health benefits (Callaghan, 2004), for some the concept of exercise may lack appeal or may prove difficult to prioritize within a daily work schedule. The use of stretching, walking, or yoga for a short amount of time may be more easily integrated into a hectic schedule. Yoga has been found to be equivalent to exercise in many mental and physical health domains, but not all types of yoga have been found to improve overall physical fitness as compared to more rigorous exercise (Ross & Thomas, 2010). The practice of yoga has been found to increase acceptance of self and others and reduce self-criticism (Valente & Marotta, 2005). Further, the regular practice of yoga can “provide therapists with a discipline capable of fostering a greater sense of self-awareness and helping to develop a lifestyle that is conducive to their own personal growth and the goals of their profession” (Valente & Marotta, 2005, p. 79).

The benefits of movement go beyond improvements in cardiac and musculoskeletal health, while serving to benefit the mind and the spirit. Dance has been used for centuries as a healing practice (Koch, Kunz, Lykou, & Cruz, 2014) and reduces stress, increases stress tolerance, and improves well-being (Bräuninger, 2012). Marich and Howell (2015) developed the practice of dancing mindfulness, which utilizes dance as the medium for practicing meditation. Dancing mindfulness participants report improvement in emotional and spiritual domains, greater acceptance of self, and an increased ability to use mindfulness in everyday life (Marich & Howell, 2015). However, caring for oneself requires more than just nutrition and movement; self-care plans should metaphorically consider the environment.

Skovholt et al. (2001; Skovholt, 2012) uses the concept of a greenhouse to describe the characteristics for a healthy work environment. Plants flourish within a nurturing greenhouse environment. Likewise, counselors thrive within a work environment that is characterized by a sense of autonomy and fairness; growth-promoting and meaningful work; reasonable expectations and remuneration; and trust, support, and respect among colleagues (Skovholt, 2012). The metaphorical work “greenhouse” contains individualized supports and resources that allow for growth and rejuvenation, but can protect the counselor from the harshness that could characterize their work. Examining and adjusting factors that may be under the counselor’s control, such as breaks between clients; scheduling of clients engaged in trauma work; number of assessments, intakes, or group sessions in one day; or other malleable elements can help create a work day that best meets the needs of the counselor. Strategic planning and focused intentionality allows the counselor to engage fully in each client encounter.

Interventions for the Spirit

Religion and spirituality are important factors within the lives of many clients (Cashwell, Bentley, & Bigbee, 2007). Within the United States, 77% of adults identify with some religious faith (Masci & Lipka, 2016). However, the United States is growing in those who identify as spiritual, with 59% of adults reporting a regular “deep sense of ‘spiritual peace and well-being’” (Masci & Lipka, 2016, para. 2). To attend appropriately and fully to clients’ religious and spiritual needs, counselors also need to care for their own spiritual selves.

Humanistic counselors engage fully with clients to create a genuine connection and are most effective as helpers in areas in which they themselves are stronger and more grounded (Baldwin, 2013). Therefore, when addressing the spiritual concerns of a client, counselors need to be aware of where they are on their own spiritual path. Otherwise, there is no assurance their own religious or spiritual concerns will not create an obstacle for their client’s growth (Sori, Biank, & Helmeke, 2006). A counselor’s spiritual concerns can influence the therapeutic alliance in many ways. Influences can include increased reactivity to the spiritual concerns of the client, decreased recognition of how the client values personal spirituality, or inattention to how the client’s spirituality may be a therapeutic resource or contributing factor to distress (Sori et al., 2006). Sori and colleagues (2006) concluded that failure to be aware of spirituality as an aspect of the human condition can create potential boundary issues, limit a counselor’s understanding of the client due to unexamined beliefs rooted in one’s own spiritual background, and result in difficulty managing the emotional uncertainty and pain of clients due to the counselor’s own struggles with faith. Therefore, engaging in reflection, exploration, or a regular spiritual practice can benefit both the counselor and the client.

Spirituality in counseling has been defined as “the capacity and tendency present in all human beings to find and construct meaning about life and existence and to move toward personal growth, responsibility, and relationship with others” (Myers & Williard, 2003, p. 149). This definition conceptualizes spirituality as a central component of wellness that shapes one’s functioning physically, psychologically, and emotionally, not as separate parts of the whole being (Myers & Williard, 2003). Valente and Marotta (2005) asserted that a healthy spiritual life can be emotionally nourishing and keep burnout at bay. Further, greater self-awareness of one’s spirituality may allow practitioners to be more present with their own suffering and that of their clients. Chandler, Miner Holden, and Kolander (1992) stated that attending to spiritual health when making personal change toward wellness will increase the likelihood of self-transformation and greater balance in life. Because there are many expressions of spirituality, individuals wishing to incorporate spirituality into their self-care plan should consider choosing activities that align with personal goals and are consistent with their values (Cashwell et al., 2007).

A spiritual self-care practice can create an inner refuge (Linder et al., 2000) that can offer sanctuary for a counselor when overwhelmed by personal or professional suffering (Sori et al., 2006). Particularly for those in the exploration phase of their own spirituality, but beneficial for all, conducting a moral inventory can assess how individuals are living in accordance with personal beliefs and values (Sori, et al., 2006). Following the moral inventory, a counselor may create a short list of principles to live by (i.e., a distilled list of values consistent with religious and spiritual ideas that are particularly personally valuable; V. Pope, personal communication, August, 2016). Individual research or joining a spiritual community can be helpful for education, support, and guidance in learning more about a particular religious or spiritual tradition (Cashwell et al., 2007). Some religious traditions, such as Seventh-Day Adventists, offer guidelines for physical and mental exercises, as well as nutritional advice that can be translated into intentional counselor self-care practices. Seventh-Day Adventists have a strong focus on wellness and advocate a vegetarian diet and avoidance of tobacco, alcohol, and mind-altering substances (General Conference of Seventh-Day Adventist World Church, 2016). Further, self-reflection may be regularly incorporated into rituals associated with an important time of year such as Lent or the Days of Awe.

For many, prayer can be a powerful practice for connecting with a higher power. Prayer is an integral part of a variety of spiritual traditions and has been associated with a variety of improvements in health and well-being (Granello, 2013). Spending time in communion with a higher power can be integrated into a regular routine for the purpose of self-care. Meditation also can be a spiritual practice and has a long history of applications and associations with health improvement (Granello, 2013). Broadly speaking, there are two types of meditation: concentration, which involves focusing attention (e.g., repeating a mantra, counting, or attending to one’s breath), and mindfulness, which non-judgmentally expands attention to thoughts, sensations, or emotions present at the time (Ivanovski & Malhi, 2007). These quiet practices can allow the participant moments of silence to achieve various ends, such as relaxation, acceptance, or centering.

Connecting with the earth or nature also can be a practice of spiritual self-care. Grounding exercises such as massage, Tai Chi, or gardening can be helpful to encourage a reconnection with the body and the earth (Chandler, et al., 1992). Furthermore, spending time in nature has been found to be rejuvenating both mentally and spiritually (Reese & Myers, 2012).

Engaging in a creative, expressive art activity for the purposes of spiritual practice and healing can be incredibly powerful to heal mind, body, and soul (Lane, 2005). Novelist John Updike has said, “What art offers is space—a certain breathing room for the spirit” (Demakis, 2012, p. 23). Art can come in many forms. Expressive arts can be a powerful tool of self-expression (Snyder, 1997; Wikström, 2005) and provide many options that can easily be used as self-care interventions. Sometimes the inner critic, need for approval, fear of failure, or a fear of the unknown can create barriers to exploring one’s creative energy (N. Rogers, 1993). Maintaining a self-compassionate attitude can allow counselors to create a safe environment to practice self-care free of judgment.

Use of dance, music, art, photography, and other media can be used intentionally for holistic healing. Through the use of clay, paint, charcoal, or other media, the creator can become in touch with feelings, gain insight, release energy, and discover alternative spiritual dimensions of the self, as well as experience another level of consciousness (N. Rogers, 1993). Music has been found to be both therapeutic and transcendental (Knight & Rickard, 2001; Lipe, 2002; Yob, 2010). There are various ways to incorporate music into a self-care plan depending on interest, access, and preference. In many cultures, music and spirituality are integrally linked (Frame & Williams, 1996). Listening to a favorite hymn, gospel music, or other type of liturgical music can be one way to revitalize the spirit during the workday. Relaxing music has been found to prevent physiological responses to stress and subjective experience of anxiety in one study of undergraduates (Knight & Rickard, 2001). Singing is another way of expressing thoughts and feelings, and for some it can provide a vehicle for self-actualization, connection to a higher power, and self-expression (Chong, 2010). After a long day, singing in the office, in the car, or while cooking dinner can be particularly cathartic.

Conclusion

Counselors are routinely exposed to painful situations, traumatic circumstances, and overwhelming emotions. Consequently, they could benefit from creating a safe place for vulnerability, especially when emotionally overwrought after a long day or a particularly difficult counseling session. To thrive as a counselor, self-care is essential, yet many struggle to care for themselves as they care for their clients. To best achieve holistic wellness, counselors must incorporate interventions for the body, mind, and spirit. Counselors can apply self-compassion principles to the creation of an individualized self-care plan, one that functions to rejuvenate flagging professional commitment and soothe potentially debilitating stress. By cultivating an attitude of self-compassion, counselors may be more attentive to their own needs, reducing the risk of developing burnout and benefitting both clients and themselves. These counselors also may be more effective in assisting clients with overcoming their own barriers to self-care. Similarly, counselors who serve as educators or supervisors can model such principles and routinely ask students and supervisees, “What do you need now?” to increase awareness and the practice of tuning in. Consequently, the self-compassionate counselor learns to create a self-care plan that becomes a balm for burnout.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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Counseling Children With Cystic Fibrosis: Recommendations for Practice and Counselor Self-Care

Mar 2, 2015 | Article, Volume 5 - Issue 2

Cassandra A. Storlie, Eric R. Baltrinic

Cystic fibrosis is a progressive, chronic disease that affects approximately 30,000 adults and children in the United States. Counseling children with the special needs specific to cystic fibrosis can be overwhelming for mental health professionals due to the progressive and deteriorating nature of the illness, long-term contact with clients, and discouraging prognosis. Being exposed to long-term therapeutic relationships with chronically ill children and witnessing treatment failure can contribute to burnout, compassion fatigue and vicarious trauma in counselors, highlighting the need for targeted literature addressing holistic self-care strategies. The purpose of this manuscript is to provide a review of the current literature illuminating the challenges facing children with cystic fibrosis and to provide targeted self-care suggestions for professional counselors working with this population.

Keywords: children, chronic disease, compassion fatigue, cystic fibrosis, self-care

Cystic fibrosis (CF) is a chronic, terminal disease targeting most organ systems (Withers, 2012) and affects approximately 30,000 children and adults nationwide (Cystic Fibrosis Foundation [CFF], 2014a). CF primarily affects the gastrointestinal and respiratory systems (Withers, 2012), and although the life expectancy has greatly improved, CF is fatal and there is no known cure (CFF, 2014a). Counseling children with chronic illnesses, such as CF, presents special challenges for mental health professionals (Sidell, 1997), including professional counselors. As the nature and severity of clients’ problems impact levels of counselor burnout or compassion fatigue (Figley, 2002), it is essential that professional counselors working with children with CF maintain healthy self-care practices.

There is an abundance of information examining the physiological aspects of CF that clients experience throughout the disease progression (CFF, 2014a; Pearson, Pumariega, & Seilheimer, 1991; Sawicki, Sellers, & Robinson, 2009; Sawicki & Tiddens, 2012). However, there is limited literature on the special considerations that need to be taken when counseling children with CF. Furthermore, there is a paucity of counseling literature targeting how professional counselors can foster personal self-care while working with young clients with special needs and chronic conditions. The purpose of this manuscript is to provide a review of literature that illuminates the challenges facing children with CF and provides a primer for self-care suggestions for professional counselors who work with these children.

Special Needs of Children with Cystic Fibrosis

Physiological Challenges Facing Children with Cystic Fibrosis

Professional counselors need to be knowledgeable of chronic diseases affecting their clients in order to be sensitive to the traumas experienced by children and families coping with illness (Thompson & Henderson, 2007). CF is most commonly diagnosed during newborn screening and severely affects the exocrine system (CFF, 2014b). Within the exocrine system, there is a lack of appropriate enzymes available during digestion, so children with CF are unable to properly digest their food and absorb essential nutrients for healthy growth and development. They experience recurrent gastrointestinal distress such as issues of diarrhea and constipation with foul-smelling stools due to poor absorption (CF Living, 2014). As such, children with CF often suffer from malnutrition and an inability to maintain a healthy weight. However, the most notable signs and symptoms affecting children with CF result from chronic lung and respiratory infections that lead to frequent coughing spells to clear the lungs of thick mucus. This inability to clear the lungs requires multiple episodes of daily chest physiotherapy (Berge & Patterson, 2004). Over time, the respiratory infections produce lung damage that appears cyst-like, giving name to the disease cystic fibrosis (CFF, 2014a).

Children with CF can spend hours per day on medical treatments such as nebulizer treatments to improve breathing, medications prior to meals to improve digestion, and oral, inhaled or intravenous antibiotics to treat respiratory infections (CF Living, 2014). However, disabilities from CF are not often visibly apparent until later stages of the disease. Decreased mobility and debilitating side effects from long-term medications, along with decreased lung capacity, all contribute to clients with CF requiring oxygen therapy for survival (Withers, 2012). The later stages of CF are inundated with frequent hospitalizations. Treatment during end-stage CF is palliative rather than curative (Lowton & Gabe, 2003), and without lung transplantation, CF remains a fatal disease due to respiratory failure (Hayes, Anstead, Warner, Kuhn, & Ballard, 2010). Nevertheless, medical breakthroughs have increased the survival rate of children with CF (Blum, 1992) and now many children are living into adulthood. Advanced clinical drug trials, aggressive antibiotic medications and innovative gene therapy research have been successful with CF clients of all ages. In 1955, children with CF were not expected to live to attend grade school. Children born with CF in this decade are projected to live into their 40s (CFF, 2014a). With this increase in life expectancy, health care teams are faced with unique challenges specific to the turbulence of adolescence and treatment compliance (Withers, 2012). Although there has been a predominant focus on treating CF based on medical science (Chesson, Chisholm, & Zaw, 2004), there is a strong interconnection of the psychosocial and physical challenges facing children and adolescents with CF. As such, professional counselors are called to increase their knowledge, skill and awareness of not just the physical challenges affecting children with CF, but also the emotional obstacles facing this population.

Psychosocial Challenges Facing Children with Cystic Fibrosis

Emotional and behavioral health disorders affect approximately 20% of all children and adolescents nationwide (Canning, Haner, Shade, & Boyce, 1992), and children with chronic illness may exhibit even higher incidences of mental health and psychosocial issues (Barnes, Eisenberg, & Resnick, 2010). For example, children with CF may experience extreme psychological challenges (e.g., depression, hopelessness, suicidal ideation) and physical complications (e.g., poor lung functioning, malnutrition) throughout the progression of their chronic condition. Taken together, these comorbidities contribute to the complexity of supporting an intense treatment modality (Anderson, Flume, & Hardy, 2001; Withers, 2012) that also promotes healthy psychosocial development and family system functioning (O’Haver et al., 2010).

In order to provide evidenced-based practices to clients with CF, as well as their families and loved ones, professional counselors need to be current on mental health research related to this special population. Studies have identified that children with CF may be predisposed to psychological issues and attachment and behavioral problems (Berge & Patterson, 2004) that may require additional training for professional counselors to effectively and efficiently counsel this population. When compared to healthy peers, children with chronic health conditions also have been found to have a slightly higher risk of attempting suicide (Barnes et al., 2010). Grief and loss, internal and external stress, negative body image, and difficulty managing emotions are common challenges experienced by children with CF (Berge & Patterson, 2004; Withers, 2012). In managing these difficulties, internalizing behaviors and anxiety also have been found prominent among this population (Berge & Patterson, 2004). Younger male children with CF have been found to exhibit higher levels of anxiety (Bregnballe, Thastum, & Schiøtz, 2007) and female children with CF have demonstrated internalizing behaviors by expressing less anger than female children without CF (Bregnballe et al., 2007).

Although research supports the idea that individuals with chronic illnesses are at increased risk for depression (Quittner et al., 2008), studies conducted on individuals with CF have provided mixed results (Pearson et al., 1991; Thompson, Hodges, & Hamlet, 1990). Berge and Patterson (2004) identified higher incidences of depression among youth with CF, whereas Tluczek et al. (2014) found that patients with CF report similar psychosocial functioning as their healthy peers. One possible factor affecting the mixed reports of depression among children with CF may include the level of disease acceptance. Previous investigations have identified that the level of disease acceptance among youth with CF can significantly lessen levels of anxiety, depression and disability in adolescents with CF (Casier et al., 2008). Nonetheless, depression and depressive symptoms have been shown to impact the progression of chronic diseases, such as CF, by increasing the likelihood that clients will be less compliant with treatment regimens and partake in risky behaviors (Quittner et al., 2008; Withers, 2012). Hence, we recommend assessing and screening for depressive symptoms frequently and examining the level of disease acceptance in clients with CF. Professional counselors working with children with CF will need to further tailor interventions based on the client’s symptom patterns (Chesson et al., 2004), while accounting for changes typical of childhood development.

Recently, scholars have researched the experiences of adolescents with CF in their transition to adulthood. This turbulent time (Withers, 2012) may need special consideration by professional counselors. Qualitative research on the experiences of adolescents with CF who were transitioning to adulthood generated the following three emerging themes: treatment compliance, health-related problems and future outlook concerning their disease (Berge, Patterson, Goetz, & Milla, 2007). Male participants described being more independent with treatment compliance, whereas females desired an accountability partner for their treatment regimen. Female participants expressed issues with depression, negative body image and fear of diabetes as a complication from CF, whereas males only disclosed their fear of acquiring diabetes as the disease progressed. Interestingly, both male and female participants expressed a positive outlook concerning CF regarding identity and acceptance of the disease (Berge et al., 2007). Identifying and maintaining a positive outlook while dealing with a chronic and debilitating illness can be a challenge for children with CF and their parents and families. Professional counselors working with youth with CF need to consider these findings. Special attention may be given to issues of treatment compliance, further physical complications from CF and maintaining a positive outlook.

Regarding risky behaviors (Quittner et al., 2008), teenagers with CF have admitted to using alcohol and drugs to seek relief from the challenges of CF (Vaeth & Martins, 2015). As such, professional counselors working with children with CF need to tailor interventions to the individuals’ symptom-specific patterns (Chesson et al., 2004) and be mindful of behaviors that may hasten the disease process. The use of alcohol and drugs may hasten the disease’s progression because of the ways in which these substances can interact with the client’s current prescription medication regimen. Alcohol use may result in pancreatitis and a hypoglycemic reaction (Withers, 2012). Likewise, clients who smoke legal and illegal substances contribute to the deterioration of lung functioning. We recommend frequently assessing and screening for substance abuse and depressive symptoms and exploring the level of disease acceptance among youth with CF in creative, developmentally appropriate ways. Importantly, professional counselors preparing counseling interventions for children with CF need to account for the added psychosocial and developmental challenges that are typical in childhood development.

Special Considerations When Counseling Children with Cystic Fibrosis

Many children share similar psychological and developmental needs as they grow (Thompson & Henderson, 2007). However, children with chronic illness may struggle to be emotionally mature, while simultaneously managing the physical symptoms of their conditions (Dahlbeck & Lightsey, 2008). Furthermore, the psychosocial complexities and the chronic nature of CF may create unique challenges for professional counselors providing services to children and their families, such as the deteriorating nature of CF, frequent hospitalizations and the life-threatening prognosis (Frels, Leggett, & Larocca, 2009; Morison, Bromfield, & Cameron, 2003). Counseling professionals’ increased sensitivity to the progression and impact of this disease can help guide their intervening efforts (Chesson et al., 2004) by leading them to consider the physiological and psychological trauma caused by CF. Professional counselors must ensure that they have developed rapport with the child as an individual, instead of a child with a disability (Thompson & Henderson, 2007).

Counseling interventions for children with CF begin with recognizing that children with CF are not adults with CF. Therefore, treatment and counseling efforts need to allow for special consideration of childhood development and understanding (Chesson et al., 2004; Geldard & Geldard, 2008). Chesson et al. (2004) offered suggestions for meeting the needs of children with chronic illnesses through counseling. First, counselors need to obtain the child’s understanding of counseling (e.g., what it is, how it will help, roles, communication). Although parental support and involvement is important when counseling children (Geldard & Geldard, 2008; Morison et al., 2003), relying solely on parental reports is not a replacement for exploring the child’s perspective of counseling (Geldard & Geldard, 2008). Chronic illnesses such as CF impact the whole family system (Kirk et al., 2013). However, within the therapeutic counseling relationship, children with CF must feel as if they are the experts on their lives and their mental health, regardless of age.

Second, counselors working with children should limit the amount of talking they do in session (Chesson et al., 2004) in favor of engaging children through natural modes of expression such as play, drawing and games. We recommend structuring counseling sessions to include discussions alongside an activity, versus a sole reliance on face-to-face conversation, in order to improve rapport building within the therapeutic relationship. Children engaging in healthy interdependent relationships with counselors can begin to develop a sense of independence and trust (Juntunen & Atkinson, 2002) within the counseling process, despite the tumultuous times during the disease progression. The adverse impact of chronic illness on social functioning (Last, Stam, Onland-van Nieuwenhuizen, & Grootenhuis, 2007) can lead to social withdrawal (Dahlbeck & Lightsey, 2008), which can be intensified when there is a concentrated focus on the child via adult approaches to counseling (e.g., making the child the center of attention to discuss his or her illness). As such, we recommend that professional counselors make age-appropriate and developmental adjustments to the counseling session and consider instituting group counseling modalities to counter the regularity of social isolation among these children.

Third, professional counselors developing a therapeutic relationship with a child experiencing CF must incorporate interactions that address the traumatic impact of living with the illness. Children with CF undergo physically stressful and painful experiences during medical treatment. Geldard and Geldard (2008) suggested that professional counselors clarify the nature of counseling and differentiate it from medical treatments. They also suggested maintaining an environment that provides acceptance and invites free disclosure. Professional counselors are urged to explain the distinction between counseling and medical procedures (e.g., there are no needles or painful medical procedures in counseling). Professional counselors also are encouraged to engage children in activities and play to reduce their level of anxiety and guardedness (Chesson et al., 2004). These targeted counseling strategies can promote resiliency factors such as self-efficacy and empowerment so that children may cope with adversity throughout the illness (Dahlbeck & Lightsey, 2008; Luszczynska, Gutiérrez-Doña, & Schwarzer, 2005). Chesson et al. (2004) further suggested that counselors gradually establish the therapeutic relationship over a number of shorter sessions in order to establish trust with the child. We caution against rushing the counseling relationship-building process and encourage professional counselors to listen openly in order to understand the child’s world.

As children struggle with chronic illnesses such as CF, acute emotional reactions are invariably triggered, which may increase the propensity for children to act out in self-injurious ways (Vaeth & Martins, 2015). The counseling process requires consistency and transparency when discussing how a child’s treatment progress will be shared among adults. Accordingly, a fourth special consideration needs to be illuminated—the limits of confidentiality. Professional counselors must illustrate the circumstances when parents will be notified of instances of self-harm or suicidal and homicidal ideation. Given the susceptibility of children with chronic illnesses to depression (Quittner et al., 2008) and suicidal ideation (Barnes et al., 2010), coping with the challenges and effects of CF are constantly in the minds of these children. Rebecca Mueller (2001) illustrated this point as a young person struggling with the illness as follows:

All the information I have about my disease has been dispersed in small pieces over time. The idea that [when] a child with CF reaches a certain age, truth and honest answers should suddenly be given is awful. With the many different sides and aspects of CF or other diseases, the information needs to come out over time, giving the person time to react and contemplate. (p. 43)

Professional counselors working with children with CF understand the need for a collaborative approach in supporting individuals and families experiencing the trauma of chronic illness. Children with chronic diseases are involved with multiple treatment professionals (e.g., dieticians, respiratory therapists, physicians, nurses, case managers, mental health and school counselors). Chesson et al. (2004) recommended that counselors assist children with understanding the decisions made by their parents, doctors and other professionals about their treatment. This task can be done by assessing the child’s knowledge of the disease process and treatment and initiating family sessions or sessions with other health care professionals when warranted. Ultimately, children who protest treatment interventions can be overridden by a caregiver’s decision. When children have a history of adult-driven decisions related to life-preserving medical treatments, this experience can make behavioral counseling interventions difficult. We suggest that counselors make every effort to respect the feelings and wishes of children with CF, including helping to “coordinate services, rearranging physical environments, removing barriers and inconveniences, and securing special equipment and materials” (Thompson & Henderson, 2007, p. 713). Professional counselors can further facilitate this supportive process by empowering children to identify and articulate their perspectives on medical treatments, given their limited choices (Chesson et al., 2004; Morison et al., 2003).

Family Involvement

Family involvement is critical to all aspects of treatment of children with CF, starting with diagnosis. Parents and families are significantly affected when their child is diagnosed with a chronic illness (Anderson et al., 2001; O’Haver et al., 2010). Thompson and Henderson (2007) explained, “The demands for energy, time, and financial resources may add a heavy burden of stress to families” (p. 602). It is essential to note that families and children face myriad stressors related to the “uncertainty and uncontrollability” of chronic illness, along with “restrictions on their freedom” (Last et al., 2007, p. 102). However, family members (particularly parents) are often responsible for providing an environment in which children can develop resiliency and independence. Family members provide a supportive environment and help to promote children’s sense of self-worth and ability to cope with challenging life situations (Juntunen & Atkinson, 2002). These tasks may be especially difficult for parents of children with CF in that they too are more vulnerable to higher incidences of depression (Quittner et al., 2008; Tluczek et al., 2014). Hence, we recommend that professional counselors working with the family system ensure that parents of children with CF have access to the emotional supports necessary to sustain family functioning and equilibrium, including participation in their own counseling as needed (Tluczek et al., 2014). Similarly, professional counselors may find it necessary to provide parent education about the CF disease process in order to help parents identify strategies to enhance resiliency in their child (Juntunen & Atkinson, 2002).

Counseling children with CF involves implementing prolonged and gradual approaches to relationship building, increasing one’s knowledge of the illness, adapting treatment approaches to account for the impact of invasive medical procedures, and involving parents, guardians and other professionals in the counseling process. Above all, honoring the perspective of the child is central to success in counseling this population, which can be easier said than done. The chronic and complex nature of CF and its treatment requires a great deal of effort and presents additional clinical challenges for professional counselors. Over time, the challenges of working with children with special needs can affect the wellness of professional counselors providing services. Therefore, it is important for counselors to recognize the factors contributing to impairment and burnout, particularly among counselors who work with children experiencing chronic illnesses like CF.

A Self-Care Primer for Professional Counselors

Professional counselors and other health professionals engaged in prolonged therapeutic contact with clients with CF are vulnerable to burnout, compassion fatigue and vicarious trauma (Coady, Kent, & Davis, 1990; Lewiston, Conley, & Blessing-Moore, 1981; Savicki & Cooley, 1987), potentially leading to impairment. Counselors have an ethical obligation to recognize their state of wellness and potential impairment (American Counseling Association [ACA], 2011), which may be impacted by burnout, compassion fatigue or vicarious trauma while working with children experiencing chronic conditions (Angerer, 2003; Kalliath, O’Driscoll, Gillespie, & Bluedorn, 2000; Najjar, Davis, Beck-Coon, & Doebbeling, 2009; Sexton, 1999) such as CF. Such occupational risks may be heightened when professionals work with clients with a poor prognosis associated with chronic illness, including CF (Coady et al., 1990).

Counselors and other mental health professionals experience occupational stressors such as long working hours, work with challenging clients, poor interdisciplinary support and poor supervision (Coady et al., 1990). Lewiston et al. (1981) examined burnout among health care providers working with clients experiencing CF. They found high levels of emotional exhaustion and client depersonalization (i.e., a sense of inability to impact clients’ improvement while watching clients’ illness progress), and a lower sense of accomplishment among health care providers working with this population. The implications of these results are intensified because “psychotherapists who work with chronic illnesses tend to disregard their own self-care needs when focusing on the needs of clients” (Figley, 2002, p. 1433).

Children with CF and their families are survivors of both medical and psychosocial traumas. Frequent trips to the emergency room, an inability to breathe, surgeries, and understanding the unpredictable and fatal progression of CF are among the traumas endured by this special population. Professional counselors who hear these traumatic stories within the therapeutic milieu must understand that vicarious trauma can occur for even the most experienced counselor. Sommer (2008) clarified that vicarious traumatization is not inadequacy on behalf of the counselor or emotional damage of the client but can be considered an “occupational hazard” (p. 52). Vicarious trauma, defined as “a traumatic reaction to specific client-presented information” (Trippany, Kress, & Wilcoxon, 2004, p. 32), also may occur among professional counselors working with children who have CF due to the erratic and terminal progression of the illness.

Professional counselors serving the CF community must recognize their vulnerabilities to burnout, compassion fatigue and vicarious trauma. Given the realities of clinical practice and responsibilities of everyday living (e.g., busy schedules, high caseloads, supervision barriers, family responsibilities, maintaining relationships), poor self-care and wellness may be easy to identify but difficult to change. In order to prevent issues of burnout, compassion fatigue and vicarious trauma, the following self-care strategies are suggested for professional counselors who work with this special population.

Self-Care Strategies for Professional Counselors

Although counselors are taught to utilize a developmental and wellness approach when working with clients (Myers & Sweeney, 2005), they often neglect their own health and well-being. Self-care strategies embedded in a wellness philosophy may help to prevent incidences of burnout among those working with the unique emotional and psychosocial stressors affecting children with CF and their families. Myers and Sweeney (2005) identified wellness as both a process and an outcome in that it is an “overarching goal for living and a day-by-day, minute-by-minute way of being” (p. 9). Self-care strategies involve managing stress in ways that limit the impact on the individual (Young, 2005). Within the counseling literature, wellness is depicted as incorporating social, emotional, physical, intellectual and spiritual dimensions (Roscoe, 2009). Counseling wellness models have been empirically supported in the counseling literature (Myers & Sweeney, 2005; Myers, Sweeney, & Witmer, 2000; Sweeney & Witmer, 1991; Witmer & Sweeney, 1992) and inform individuals about methods to limit their stress and maintain a healthy sense of well-being. Hence, we recommend that professional counselors use multidimensional, holistic self-care strategies to maintain a sense of wellness when working with youth experiencing special needs. The following section provides physiological, cognitive and spiritual wellness strategies for professional counselors to use while working with children with CF and other chronic conditions.

Physiological self-care strategies. Professional counselors are accustomed to working with clients regarding wellness and self-care but may not always practice their own healthy suggestions. Self-care strategies that are body-focused may help alleviate the impact of stress (Young, 2005), particularly among those working with children with special needs such as CF. Young (2005) recommended approaches such as progressive relaxation, balanced exercise and nutrition, and adequate rest to assist with integrating a wellness focus and enhancing self-care. A healthy diet and physical activity are readily known to prevent physical and mental health conditions, while also increasing energy levels. Furthermore, “minding the body” and having adequate sleep and bodily rest are additional suggestions for restoring self-care as a priority for professional counselors (Norcross & Guy, 2007, pp. 64–65). Professional counselors interested in implementing physiological self-care strategies to address potential issues of vicarious trauma while working with children diagnosed with CF may consider simple tasks such as taking a brisk walk during their lunch break, joining a gym, or being more intentional with their diet and bedtime routines. In addition to focusing on physical health and wellness, self-care in the cognitive domain is equally important for fostering a sense of well-being.

Cognitive self-care strategies. Stress from occupational risks accumulated through working with youth with special needs may be further prevented if counselors utilize cognitive approaches to support their own self-care. Professional counselors interested in improving their self-care in cognitive ways may consider cognitive restructuring to formulate new thinking patterns and assertiveness training to bring about direct changes in behaviors that may have been impacted by stress (Young, 2005), which often accumulates during the long-term therapeutic relationship with children and families affected by CF. Moreover, the use of guided imagery may provide both cognitive and physical benefits in helping to create a cognitive break from daily stress inside and outside the workplace. Notably, cognitive self-care strategies begin with self-monitoring, insight and self-awareness (Norcross & Guy, 2007). Despite counselors’ close therapeutic connection to clients with CF and their families, healthy boundaries are imperative to prevent issues of burnout and compassion fatigue. Norcross and Guy (2007) noted that “setting boundaries consistently emerges in the research as one of the most frequently used and one of the most highly effective self-care principles” (p. 94). Due to counselors’ innate desire to help others, they often take on too many clients or are mandated to do so by agency policies. Counselors may provide extra time to ancillary responsibilities and have unrealistic expectations of themselves. As such, we recommend that professional counselors obtain good supervision to help manage and maintain work–life balance, particularly when working with children with special needs. In addition to the benefits of physical and cognitive self-care strategies, spirituality also has been shown to enhance levels of wellness and thus decrease the potential for burnout and compassion fatigue.

Spiritual self-care strategies. Spirituality comes in many forms and there is no finite definition of how one engages in his or her spiritual self. Many counselors and psychotherapists identify their own career path as a calling to care for others and commitment to growth and self- knowledge (Norcross & Guy, 2007). Research supports that spirituality, prayer and meditation are positive manners in which to promote wellness and augment self-care (Cashwell, 2005). Spiritual beliefs, practices and experiences are intricately connected and may continue to foster support from communities and individuals, along with reinforcing healthy emotions. While working with children experiencing the later stages of CF, professional counselors’ spirituality may help them connect with clients on a more meaningful level. Taking a spiritual perspective can further shape counselors’ perspective on life events (Young, 2005), particularly when they are grieving the death of a child with CF. In seeking a spiritual connection to a higher power, the negative responses to stressful events may be limited (Young, Cashwell, & Shcherbakova, 2000), strengthening one’s wellness and ability to care for oneself. These actions, along with discussing spirituality with the child and family affected by CF, may further model healthy practices during difficult times in the disease process.

Spiritual self-care can include the use of mindfulness, which can be viewed as the nonjudgmental awareness of one’s own inner suffering (Birnie, Speca, & Carlson, 2010) and reflections on self-compassion (Neff, 2003). Birnie et al. (2010) described self-compassion as the awareness of “feelings of caring and kindness towards oneself in the face of personal suffering” and the “recognition that one’s suffering, failures, and inadequacies are part of the human condition” (p. 2). When counseling children with CF, professional counselors may consider routinely expressing self-compassion as part of their inner dialogue. The following mantra used by the second author may be of assistance to professional counselors implementing spiritual self-care:

Suffering is part of life. My clients suffer, but did not choose this illness. They are walking in its wake and I will walk alongside them. I will extend loving kindness in all the work I do, despite the pain and suffering I experience and witness.

We highlight the following three essential components of self-compassion: (a) extending kindness and understanding toward oneself rather than harsh judgments or criticism, (b) recognizing that suffering (even chronic illness) is a part of the larger human condition, and (c) not overidentifying with the awareness of one’s painful thoughts (Birnie et al., 2010; Neff, 2003). By engaging in self-compassion and mindfulness, professional counselors may help to prevent incidences of compassion fatigue while working with children and families affected by CF by recognizing that this illness has a role in their humanity.

Conclusion

Professional counselors working with children and families affected by CF should consider the physical and psychosocial challenges facing this special-needs population. With the discouraging nature of the disease progression, professional counselors must have a basic understanding of the client’s chronic condition (Thompson & Henderson, 2007) and how the progression of the illness affects the child’s emotional state. Professional counselors must further explore how to limit the impact of occupational stress that may lead to burnout, compassion fatigue and vicarious trauma. This article provides a primer on the physiological, psychosocial and special needs specific to youth with CF and offers targeted self-care strategies for professional counselors. Children with CF are a special population and professional counselors are called to implement these special considerations in their thoughtful practice. There is an abundance of literature examining the physiological aspects of CF (CFF, 2014a; Pearson et al., 1991; Sawicki et al., 2009; Sawicki & Tiddens, 2012). However, more research is warranted to examine the salient factors that affect the therapeutic relationship between professional counselors and children with CF. Meanwhile, professional counselors can develop and implement individualized, multidimensional self-care strategies to counter the effects of this difficult yet rewarding work.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.

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Cassandra A. Storlie, NCC, is an Assistant Professor at Kent State University. Eric R. Baltrinic is an Assistant Professor at the University of Toledo. Correspondence may be addressed to Cassandra Storlie, 310 White Hall, PO Box 5190, Kent, OH 44242, cstorlie@kent.edu.

Self-Care Through Self-Compassion: A Balm for Burnout

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