Ariann Evans Robino
Explanations of compassion fatigue generally consider the client–counselor relationship as the primary source of challenges to wellness. Because of the nature of the current sociopolitical climate and the increased exposure through media, the counseling profession should consider expanding the influences on compassion fatigue related to current events. This article introduces the concept of global compassion fatigue (GCF), a phenomenon that provides an opportunity for counselor self-awareness. Implications for adopting GCF into the counselor impairment literature include understanding how global events impact counselor development and clinical practice as well as the importance of maintaining a wellness lifestyle to protect against its effects. Counselors’ involvement in advocacy and social justice are also explored as contributors to GCF.
Keywords: global compassion fatigue, counselor impairment, advocacy, self-awareness, wellness
Counselors and counselors-in-training (CITs) feel the weight of societal stressors. According to the ACA Code of Ethics, “promoting social justice” (American Counseling Association [ACA], 2014, p. 3) is a core value of the counseling profession. Furthermore, because of its impact on the profession, scholars have declared social justice as the fifth force in counseling (Ratts, 2009; Ratts, D’Andrea, & Arredondo, 2004). Representatives from ACA have acted in accordance by addressing the federal government’s recent prohibition of specific language associated with diverse populations (Yep, 2017) as well as releasing a statement of support shortly after the 2016 presidential election calling on all counselors to remain strong in their beliefs and actively assist those in need (Roland, 2016). Similarly, the closing keynote speaker at ACA’s Illuminate Symposium on June 10, 2017, Dr. Cheryl Holcomb-McCoy, encouraged attendees to take action against human rights offenses through vocal opposition in multiple settings, including social media (Meyers, 2017). These positions demonstrate the desired role of counselors to engage in advocacy and activism for global issues.
Natural disasters, threats to civil rights, violence, terrorist attacks, and animal welfare concerns are simply a few of the powerful issues that humans face as highly social and emotional beings. Although advocacy is one avenue of handling the emotional unrest related to these events, the complex nature of counselors’ personal and professional identities presents an invitation to consider these sensitive issues currently faced by society. Professional counselor identity allows counselors to make meaning of their work during these times of strong emotion (Solomon, 2007). Considering how these events affect both counselors’ and CITs’ personal lives and clinical practice produces opportunities for counselor professional development and greater self-awareness. The purpose of this article is to explore global compassion fatigue (GCF), a phenomenon related to the human condition and how global events impact professional counselors and other helpers. This article begins with a review of current counselor impairment concepts as well as the role of wellness in managing these conditions. Then, the reader is introduced to GCF and how a review of the literature supports the examination of this new concept. Next, I provide a detailed conceptualization of the phenomenon and implications for the field. Finally, suggestions for future research are provided.
Understanding Compassion Fatigue
Compassion fatigue research spans the literature of multiple disciplines, including nursing, social work, and counseling (Compton, Todd, & Schoenberg, 2017; Lynch & Lobo, 2012; Sorenson, Bolick, Wright, & Hamilton, 2016). Counselors typically understand compassion fatigue as an event occurring as a result of counselor–client interaction. Charles Figley (1995) first defined the concept of compassion fatigue as “a state of exhaustion and dysfunction—biologically, psychologically, and socially—a result of prolonged exposure to companion stress and all that it evokes” (p. 253) and conceptualized it as a response to the emotional demands of hearing and witnessing stories of pain and suffering. Symptoms of compassion fatigue include re-experiencing the client’s traumatic event, avoidance of reminders of the event and/or feeling numb to those reminders, and persistent arousal (Figley, 1995). Researchers carefully note the differences between compassion fatigue, vicarious traumatization, and burnout (Lawson & Venart, 2005; Meadors, Lamson, Swanson, White, & Sira, 2010). Vicarious traumatization, defined as a significant altering of cognitive schemas and a disruption of an individual’s sense of identity, worldview, and meaning, occurs as a result of empathic engagement with the traumatic experiences of a client (McCann & Pearlman, 1990). Vicarious traumatization symptoms involve a more covert change in thought and cognitive schema rather than an observable experiencing of symptomatology (Jenkins & Baird, 2002). Burnout is a process that occurs because of occupational stressors such as high caseloads, low morale, and minimal support (Maslach & Jackson, 1981). It is associated with emotional exhaustion, strain, and overload in addition to a reduction in personal accomplishment and job satisfaction (Maslach, 1982). Counselors are more likely to experience compassion fatigue, vicarious traumatization, and burnout when they have a previous history of personal trauma (Baird & Kracen, 2006), high emotional involvement with clients (Adams, Boscarino, & Figley, 2006), fewer perceived coping mechanisms (Baird & Kracen, 2006), and lower self-awareness (P. Clark, 2009). However, the goal of this article is to expand upon the phenomenon of compassion fatigue as distinguished from these other explanations of impairment to understand better how global events outside of the counselor–client dyad impact counselors. Although other impairment concepts hold value and applicability to counselors, compassion fatigue and its relationship to emotional suffering as a result of a desire to help others most closely aligns with the concept presented in this article. When considered in the context of counselors, an awareness of compassion fatigue, its effects, and how to mitigate those effects is vital for client welfare.
Counselor Impairment and Wellness
According to the ACA Code of Ethics, counselors should “monitor themselves for signs of impairment from their own physical, mental, or emotional problems” (ACA, 2014, p. 9). The ACA Code of Ethics dedicates an entire section to counselor impairment (C.2.g.), which states that, in the interest of client protection, counselors should cease providing services while impaired, seek assistance to solve issues of impairment, and assist colleagues and supervisors in recognizing and rectifying their own impairment (ACA, 2014). When counselors are impaired, it can result in significant harm to clients through an interference with the counseling process, trust violations, and ethical breaches (Lawson, Venart, Hazler, & Kottler, 2007). Adopting an alternative lens for viewing the impairment literature presents an opportunity for counselors to monitor themselves and others for potential issues as indicated by the ACA Code of Ethics (ACA, 2014). In addition, the ACA Code of Ethics guides counselors to “engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to meet their professional responsibilities” (ACA, 2014, p. 8). As self-advocacy for wellness can promote better professional practice within the counseling community (Dang & Sangganjanavanich, 2015), counselors are encouraged to avoid and rectify issues of impairment through positive, health-promoting strategies.
Recognizing this area of need within the profession, ACA established the Taskforce on Counselor Wellness and Impairment in 2003 to address the needs of impaired counselors (Lawson & Venart, 2005). The taskforce identified goals for education for counselors on impairment and how to prevent it, securing treatment for impaired counselors, teaching self-care strategies, and advocating within the organization and at both the state and national levels to address issues associated with impairment. Although the taskforce focused on the broader topic of impairment, compassion fatigue remains a component of this experience. The creation, cultivation, and maintenance of a wellness lifestyle is a primary means of addressing and rectifying counselor impairment and compassion fatigue (Lawson & Venart, 2005).
Wellness is defined as “a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully” (Myers, Sweeney, & Witmer, 2000, p. 252). Wellness and prevention are core components of counselors’ professional identities (Mellin, Hunt, & Nichols, 2011). As a result, researchers have studied the benefits of wellness strategies for counselors (Cummins, Massey, & Jones, 2007), counselor educators (Wester, Trepal, & Myers, 2009), and CITs (Yager & Tovar-Blank, 2007). Additionally, Figley (1995) specifically identified poor self-care as a primary risk factor for experiencing compassion fatigue, and Chi Sigma Iota’s (CSI; n.d.) advocacy themes, specifically Theme 6, outline the need for advocacy related to prevention and wellness for clients and counselors (Lee, 2012). The development of a taskforce, the extensive literature associated with compassion fatigue and wellness, and CSI’s identification of wellness as an area of advocacy indicate a clear relationship between counselor experience and counselor practice. Based on previous research, ACA’s stance on counselor self-care, and humans’ innate desire to engage in complex processes to achieve optimal functioning and well-being, it is beneficial for counselors to consider a new phenomenon related to their consistent exposure to global issues through media and social media. Counselors currently conceptualize compassion fatigue as a linear process occurring as a result of the cumulative direct exposure to clients’ distressing experiences. This article presents an expanded perspective on counselor compassion fatigue occurring as a result of exposure to current events and issues. Furthermore, this article offers a language for this experience as well as a conceptualization of the phenomenon.
I suggest the term global compassion fatigue to describe the process by which an individual experiences extreme preoccupation and tension as a result of concern for those affected by global events without direct exposure to their traumas through clinical intervention. GCF requires examining compassion fatigue outside of client-specific experiences and within a larger context. This invites counselors and CITs to explore how they are human and existing in a conflicted, polarized, and oftentimes troubling world.
Figure 1 provides a visual depiction of these constructs. After exposure to a traumatic global event, humans experience an acute stress-related psychological response (Holman, Garfin, & Silver, 2013); for counselors this may manifest as GCF because of their foundational helping skills rooted in the ability to feel and exhibit empathy for the issues faced by others (A. J. Clark, 2010). Once this response occurs, counselors can utilize wellness and self-care strategies and engage in social justice advocacy efforts as deterrents to GCF. If they bypass these methods, they might experience the extreme preoccupation and tension that are indicators of GCF. However, counselors can interrupt and manage their GCF by moving to wellness and advocacy strategies.
Figure 1. Process of GCF. After media exposure to a global event and engaging in an emotional response, counselors can immediately experience GCF. Wellness and advocacy are two methods of either addressing GCF after experiencing it or through prevention to deter the experience.
GCF differs from vicarious traumatization in that it does not denote permanent change in cognitive schema; rather, a counselor can experience GCF transiently and in response to significant global and communal events. Counselors experiencing GCF do so outside of clients’ presenting problems. Although no current counseling literature describes this phenomenon, Stebnicki (2007) proposed the concept of empathy fatigue, which “results from a state of emotional, mental, physical, and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss” (p. 318). Whereas GCF does bear similarity to empathy fatigue, empathy fatigue remains related to an occurrence resulting from direct clinical exposure (Stebnicki, 2007), and GCF involves counselor introspection unrelated to session content. Relatedly, Bayne and Hays (2017) recently conducted a study to conceptualize the conditions of empathy within the counseling process. They developed an exploratory model of counselor empathy that acknowledges the multidimensionality of the empathic process, including the variables associated with counselor impairment. GCF proposes that counselors’ intense emotional experiences related to global concerns are associated with empathy and a desire to help those directly affected. Current events that may cause a counselor to experience GCF include politics, natural disasters, violence (including mass shootings), terrorist attacks, threats to human rights, and animal abuse.
Compassion fatigue research is the best point of reference when considering the experience of GCF. Compassion fatigue manifests through physical, psychological, spiritual, and social symptoms (Lynch & Lobo, 2012), and counselors experiencing GCF also can exhibit these symptoms. However, counselors must consider the source of their feelings of fatigue. For example, Coetzee and Klopper (2010) noted, “compassion fatigue is caused by the prolonged, intense, and continuous care of patients, use of self, and exposure to stress” (p. 239). I suggest that GCF involves a similar experience, although as a result of continuous concern for other beings, a desire to help recover from or solve the issues affecting those beings, and repeated exposure to current events harming individuals on a large scale. Additionally, ACA’s Advocacy Competencies call for professional counselors to engage in systemic and sociopolitical advocacy on a continuum ranging from the microlevel (i.e., the individual) to the macrolevel (i.e., the public; Lewis, Arnold, House, & Toporek, 2003). Therefore, it is a counselor’s duty to remain aware of systemic, environmental, and political factors impacting clients in addition to immersing themselves in advocacy and mechanisms for change. Such actions may leave counselors susceptible to impairment in response to global issues, although moving from awareness to action also can help prevent or mitigate GCF.
Researchers have explored the effects of distressing events on helping professionals. Early research described the relationship between clergy members’ compassion fatigue and their time spent with trauma victims following the September 11th terrorist attacks (Flannelly, Roberts, & Weaver, 2005). Counselors responding after a natural disaster (Lambert & Lawson, 2013) and trauma counselors (Sansbury, Graves, & Scott, 2015) are populations often researched in the compassion fatigue literature. For example, Day, Lawson, and Burge (2017) reported the results of a qualitative research study exploring compassion fatigue and shared trauma in clinicians providing services after the shootings at Virginia Tech in 2007. Day et al. raised an interesting point between a counselor’s direct and indirect exposure to global events as well as the level of impairment resulting from the experience. Given the possibility that unresolved trauma can cause issues in functioning, direct exposure to an event removes the possibility that a counselor is experiencing GCF. This shared trauma may result in similar symptomatology, but these symptoms are attributed to the commonality of the trauma experience (Figley Institute, 2012).
From a different framework, researchers have explored the experiences of non-counselors when exposed indirectly to traumatic global events. Although many Americans were not in New York at the time of the September 11th attacks, nor were they likely to have known someone associated with the attacks, the stress of the event was felt across the country in the form of trauma symptoms (Schuster et al., 2001). Individuals living in Britain also experienced psychological changes as a result of the vicarious media exposure to these terror attacks on America (Linley, Joseph, Cooper, Harris, & Meyer, 2003). Similarly, college students at a separate university described an increase in acute stress symptoms as they learned about the shootings at Virginia Tech on television (Fallahi & Lesik, 2009). This research indicates that individuals can experience emotional duress in response to indirect exposure to global or national issues. Ultimately, it is important to remember that, despite extensive training and experience, counselors are humans navigating a society that can upset them in various ways. GCF awareness furthers counselor insight and promotes opportunities for evaluating self-care, wellness, and efficacy under these conditions. Such awareness requires an understanding of the role media plays in individuals’ experiencing of traumatic global events.
The Impact of Media
Previous researchers evaluated the impact of television viewing on an individual’s stress symptoms and levels of vicarious exposure (Fallahi & Lesik, 2009; Linley et al., 2003), suggesting that the role of technology can significantly affect a counselor’s ability to create boundaries and step away from the tragic circumstances occurring in the world around them. With 62% of adults obtaining their news from social media sites in 2016, an increase from 49% in 2012 (Gottfried & Shearer, 2016), it is clear that regular social media use can result in high levels of exposure to distressing news content. Additionally, four out of five adults in the United States reported constantly “checking” their cellular phones for emails, text messages, and social media (American Psychological Association, 2017). This same survey also described higher stress levels in the “constant checker” population than those using technology less frequently.
Researchers have discovered a link between emotional well-being and use of television media. Schlenger et al. (2002) found a statistically significant relationship between the levels of post-traumatic stress disorder symptoms and the numbers of hours spent watching television coverage of the September 11th terrorist attacks when assessing the psychological reactions of 2,273 adults residing in major metropolitan cities in the United States one to two months after the attacks. Fallahi and Lesik (2009) also identified a problematic association between indirect exposure to a tragic event through news media sources and symptoms of acute stress disorder.
Therefore, if a counselor or CIT is particularly sensitive to the content to which they are exposed through the media, they increase their risk of experiencing GCF. Conversely, social media also might provide an opportunity for community and connection in the face of global issues. The idea of community is no longer constrained within the bounds of physical associations; rather, the internet provides access to distant communities and relationships (Gruzd, Wellman, & Takhteyev, 2011). Supporters and activists involved in the Black Lives Matter movement are an example of such a community. Black Lives Matter erupted on social media as a Twitter hashtag created to raise awareness for and demonstrate protest against police brutality on members of the Black community (Petersen-Smith, 2015). Through this online movement, individuals were able to exhibit solidarity and take a stand against racism toward Black people with their use of social media (Schuschke & Tynes, 2016). Similarly, the #MeToo internet-based movement brought attention to women’s rights and sexual violence (Hostler & O’Neil, 2018), and social media platforms also provide a method of addressing the stigma of mental health and addiction (de la Cretaz, 2017).
ACA has an active social media presence through online pages and forums on their website, Facebook, Twitter, and LinkedIn (ACA, 2017). The ACA Code of Ethics (ACA, 2014) states that counselors will use social media only when it is in the best interest of the client while protecting their identity and well-being (Section H). This is another example in which a position is based on a situation specifically involving the client and counselor. Although researchers have explored the role of social media in counselor education (Tillman, Dinsmore, Chasek, & Hof, 2013) and recommendations have been made for using social media ethically in clinical practice (Giota & Kleftaras, 2014), researchers have yet to explore how social media affects practicing counselors on an emotional level. Adopting GCF into the counselor impairment literature would suggest a need for ACA to also establish recommendations for counselors’ social media use and how excessive exposure to global events can affect their work as counselors.
A New Perspective
As social beings dependent upon one another for survival, humans have an evolutionary and biological drive to feel connected and invested in others. Specifically, humans are interested in the welfare of others on a neurological level (Lieberman, 2013). Counselors and CITs can feel a need to help others based on evolutionary compulsions rooted in social psychology. However, they also can feel this drive to an amplified extent because of their consistent demonstration and use of empathy, a foundational helping skill that allows counselors to “enter the client’s phenomenal world, to experience the client’s world as it were your own without ever losing the ‘as if’ quality” (Rogers, 1961, p. 284). Although all humans are susceptible to experiencing fatigue as a result of high exposure to global issues through media, not all humans work in a helping profession based in the empathic experience. Therefore, similar to the need for counselors to monitor themselves for impairment as a result of direct engagement with clients’ presenting issues, counselors also need to monitor for impairment from global issues. Regardless of continuous exposure to distressing global events, counselors continue to help others on a consistent basis. This indicates a critical need for counselors to understand their relationship to social media and the global events to which they experience an emotional response.
Symptoms of GCF can manifest similarly to traditional compassion fatigue. These symptoms can include emotional and physical exhaustion associated with care for others, desensitization to stories and experiences, poorer quality of care, feelings of depression or anxiety, increased stress, difficulty concentrating, and preoccupation (Figley Institute, 2012). Ultimately, it is the responsibility of the counselor to understand the source of these symptoms. Unlike counselors’ direct work with clients in which there may be greater opportunities to assist in managing or addressing a pain-inducing problem, emotional and cognitive responses to global issues present a different type of challenge. Managing issues in which a person may perceive little control and direct influence can cause responses such as rumination (Nolen-Hoeksma, Wisco, & Lyubomirsky, 2008) and fear (Pain & Smith, 2008). Although counselors can experience these feelings regarding clients (Sansbury et al., 2015), there are greater opportunities for direct interaction with the client needing assistance. In most cases, counselors are unable to directly impact the people involved in the global events to which they are continuously exposed through media and social media. Optimal human functioning involves integration of the mind, body, and spirit (Myers et al., 2000). GCF can impact this integration when counselors are unable to live fully through the exhaustion of exposure to global events. Wellness strategies and forms of advocacy can prevent or rectify these experiences. Myers et al. (2000) acknowledged that “global events, whether of natural (e.g., floods, famines) or human (e.g., wars) origin, have an impact on the life forces and life tasks depicted in [wellness models]” (p. 252). In addition, advocacy in the wake of social events can provide feelings of efficacy and social connection (Scott & Maryman, 2016). This new perspective provides implications for the profession of counseling, including recommendations, cultural considerations, and areas of future research.
Implications for Counselors
In a “plugged-in” society, it is possible to become overwhelmed with the daily stream of news and information. Additionally, counselors can be at higher risk of experiencing impairment because of their empathic nature (Figley, 1995) and ethical duty to engage in social justice for causes that improve equity for individuals and groups (ACA, 2014). As leaders and advocates, GCF may be present in counselors’ daily clinical work. Licensed counselors in private practice may not be receiving ongoing supervision (Bernard & Goodyear; 2014); therefore, no external individual is monitoring how they are managing GCF and its effects. Counselors outside of supervision must exercise great care to practice self-awareness and approach others for assistance. Furthermore, counselors in high-volume settings often work with large caseloads that present with complex issues (Belling et al., 2011; Lombardo, 2018), and it may be easy for them to ignore their own needs while addressing the needs of others. Given the critical period of counselor development, GCF also must be considered within the context of counselor education. GCF during the formative period of graduate-level education in counseling can impede overall skill development. As new counselors find themselves more likely to experience compassion fatigue (Figley, 1995), the same may hold true for GCF. GCF may result in a type of developmental stalling in which counseling students feel an “empathy overload.” Such an overload of empathic emotions may impede the student’s transformation into a counselor. This provides implications for counselor education programs to measure students’ responses to emotionally distressing stimuli (O’Brien & Haaga, 2015) of both clinical and global nature as well as openly and unashamedly discuss signs and symptoms of impairment (Merriman, 2015).
I propose that counselors can manage GCF similarly to compassion fatigue because of the possibility of the two phenomena appearing symptomatically similar. However, GCF requires a greater level of self-awareness, recognition, and acceptance in order to address it. Counselors must learn how to distinguish between the two concepts and understand the possibility for overlap. A number of tools used to manage compassion fatigue can be used for GCF. Supervision, personal counseling, and consultation are all avenues of accountability, monitoring, and fidelity to the profession (Bernard & Goodyear, 2014). Although advocacy can be another tangible method of preventing or mitigating GCF, activism can cause emotional, mental, and physical exhaustion (Chen & Gorski, 2015); therefore, advocacy paired with careful attention to wellness can allow counselors to be most effective in helping to address global issues (Roysircar, 2009). Self-care practices and a wellness lifestyle may also act as protective factors to GCF. Myers et al. (2000) noted, “If one’s spirituality is healthy . . . [it] provides a firm foundation and core for the rest of the components of wellness” (p. 258). This indicates counselors developing an optimistic outlook in response to global events creates greater buffering or management of GCF. Similarly, these authors also state that self-direction allows a person to “move smoothly through time and space”
(p. 258). The cumulative pressure of global stressors necessitates firm self-direction to maintain focus in the chaos of present time and space. Wellness is cumulative and enhances longevity for professional practice (Myers et al., 2000). Ultimately, counselors are ethically responsible for ensuring they practice healthy boundaries and work within their competencies (ACA, 2014). An open dialogue with colleagues, self-awareness of strong responses to global events, pursuing systemic change through advocacy, and cultivating personal wellness encourage management of GCF (Robino & Pignato, 2017).
GCF holds particular relevance for counselors of color. Individuals from historically marginalized populations must understand, identify, and address their experiences and the effects of systemic and individualized racism as well as the psychological trauma of oppression and marginalization (Carter, 2007). The number of publicized events that occur in relation to civil rights issues and social justice concerns warrant additional consideration of GCF in specific populations. For example, police brutality against Black males can cause GCF in many counselors, particularly in counselors of color because of the negative psychological health outcomes for communities of color that stem from racism and discrimination (Carter & Forsyth, 2009; Comas-Díaz, 2016). Furthermore, violence (e.g., the Charleston, South Carolina, shooting targeting a specific religious group consisting of people of color and the Charlottesville, Virginia, protests that resulted in the death of a counter-protester) and localized natural disasters (e.g., fires in Tennessee and the Western United States that affected entire communities and hurricanes like Harvey, Irma, and Maria that caused devastation in the Southern United States and Puerto Rico) also increase the risk of GCF in counselors indirectly or somewhat directly exposed to these events. At the time of this writing, the president of the United States has signed an Immigration Executive Order (Executive Order No. 13,769, 2017) that calls for banning residents of certain Middle Eastern countries from entering the United States. In addition, the public expressed outrage at the removal of children from families seeking asylum at the U.S.–Mexico border (Goldstein, 2018). Such traumatic events become a systemic, multi-level public health issue (Magruder, McLaughlin, & Elmore Borbon, 2017) and increase the possibility of GCF among concerned individuals, including counselors and counseling students.
The emergence of this concept paves the way for a broad range of research avenues. First, I recommend the study of GCF in counselor education programs. With CITs particularly sensitive to the nuances of the counseling profession (Bernard & Goodyear, 2014), the critical period of graduate education requires an examination into how GCF can affect counselor development. Second, the management of GCF calls for greater practice of self-care and exercising of insight. For example, researchers could explore the use of mindfulness and reflexivity in assessing how to treat counselors impacted by global events. Additionally, future research could explore the relationship of counselors’ social media use and GCF experiences. Statistics indicating the increase of social media as a news source (Gottfried & Shearer, 2016) raise questions of how counselors are impacted by their own internet activity. Researchers also could investigate counselor advocacy on social media. Although this article proposes that counselors may experience frustrations that contribute to GCF as a result of social media exposure to distressing global events, Dr. Holcomb-McCoy described social media as a tool for advocacy (Meyers, 2017), which may help in mitigating GCF. Such studies may assist counselors in delineating between GCF and other phenomena of impairment.
Finally, greater research is needed to assess and measure GCF. No accurate measurement yet exists for the phenomenon of GCF. Compassion fatigue measurements assess the negative aspects of helping others through direct contact (Figley, 1996). For GCF, this does not address the negative aspects of compassion for indirect exposure to global events. The Impact of Events Scale-Revised (IES-R; Weiss, 2007) measures the subjective distress associated with a traumatic event. However, the IES-R measures symptoms associated with post-traumatic stress disorder. Although it captures the experience of an external global event, it does not capture the transient, yet profound, emotional experience of GCF. The answer to assessing GCF may lie in the development of an instrument that combines compassion fatigue assessments and the IES-R to measure GCF symptoms as it relates to global events.
This article introduces the concept of GCF into the counseling literature. By expanding the literature on other explanations of impairment, we broaden opportunities for self-awareness and professional development. Previously researched impairment concepts require an expansion into this new perspective by incorporating the effects of exposure to current events. This new phenomenon also contributes to counselor wellness research and the importance of maintaining a healthy wellness lifestyle as a deterrent to GCF. Adopting this concept and language into the literature on impairment and wellness encourages further consideration of counselor health, counselors’ management of distressing global events, and how this may impact both counselors and clients as humans.
As counselors become competent in their roles as advocates for social justice, their involvement in critical global events necessitates attention to the cumulative toll such a role may entail. In addition, consistent exposure to emotionally debilitating global events through social media places counselors in a peculiar position in which they must balance their need to remain informed of events and their need to remain healthy and well. Counselors carry the extra responsibility of remaining present and empathic with their clients while also protecting the empathy they experience for the world around them. Counselors’ marginalized and impacted cultural identities also factor into their experiences of GCF. In this regard, wellness becomes not simply an ethical duty, but also a professional imperative in the interest of both counselor and client welfare.
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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Nesime Can, Joshua C. Watson
Scholars have described compassion fatigue as the result of chronic exposure to clients’ suffering and traumatic stories. Counselors can struggle when they experience compassion fatigue because of various reasons. As such, an exploration of factors predictive of compassion fatigue may help counselors and supervisors buffer adverse effects. Utilizing a hierarchical linear regression analysis, we examined the association between wellness, resilience, supervisory working alliance, empathy, and compassion fatigue among 86 counselors-in-training (CITs). The research findings revealed that resilience and wellness were significant predictors of compassion fatigue among CITs, whereas empathy and supervisory working alliance were not. Based on our findings, counselor educators might consider enhancing their current training programs by including discussion topics about wellness and resilience, while supervisors consider practicing wellness and resilience strategies in supervision and developing interventions designed to prevent compassion fatigue.
Keywords: compassion fatigue, counselors-in-training, wellness, resilience, supervisory working alliance
Balancing self-care and client care can be a challenge for many counselors. When counselors neglect self-care, they can become vulnerable to several issues, including increased anxiety, distress, burnout, and compassion fatigue (Ray, Wong, White, & Heaslip, 2013). Counselors might be especially prone to experiencing compassion fatigue because they repeatedly hear traumatic stories and clients’ suffering in sessions (Skovholt & Trotter-Mathison, 2016). This phenomenon is likely pronounced among counselors-in-training (CITs), as lack of experience, skillset, knowledge, and support can lead to struggles when working with clients (Skovholt & Trotter-Mathison, 2016). Coupled with the increased anxiety, distress, and disappointment, CITs can experience compassion fatigue early in their career development, which can lead to exhaustion, disengagement, and a decline in therapeutic effectiveness (Rønnestad & Skovholt, 2013). At this developmental stage, negative experiences can lead to feelings of doubt and a lack of confidence among CITs and potentially lead to career dissatisfaction. Therefore, it is essential and necessary to better understand the predictive factors of compassion fatigue among CITs to prevent its early onset.
Compassion Fatigue in Counseling
Counselors listening to their clients’ fear, pain, and suffering can feel similar emotions. Figley (1995) defined this experience as compassion fatigue; it also can be defined as the cost of caring (Figley, 2002). Whether working in mental health agencies, schools, or hospital settings, counselors experience compassion fatigue because of exposure to large caseloads, painful stories, and lack of support and resources (Skovholt & Trotter-Mathison, 2016). Despite this exposure, counselors are expected to place their personal feelings aside and provide the best treatment possible in response to the presenting issues and needs of their clients (Figley, 2002; Ray et al., 2013; Turgoose, Glover, Barker, & Maddox, 2017). Maintaining this sense of detached professionalism has its costs, as a number of counselors find themselves at risk for experiencing physical, mental, and emotional exhaustion, as well as feelings of helplessness, isolation, and confusion—a situation collectively referred to as compassion fatigue (Eastwood & Ecklund, 2008; Thompson, Amatea, & Thompson, 2014).
Merriman (2015b) stated that ongoing compassion fatigue negatively impacts counselors’ health as well as their relationships with others. Additionally, compassion fatigue can lead to a lack of empathy toward clients, decrease in motivation, and performance drop in effectiveness, making even the smallest tasks seem overwhelming (Merriman, 2015b). When this occurs, counselors can project their anger on others, develop trust issues, and experience feelings of loneliness (Harr, 2013). Therefore, the demands of the counseling profession can affect many counselors’ wellness and potentially could hurt the quality of client care provided (Lawson, Venart, Hazler, & Kottler, 2007; Merriman, 2015a). Further, counselors experiencing compassion fatigue might have difficulties making effective clinical decisions and potentially be at risk for harming clients (Eastwood & Ecklund, 2008). Consequently, scholars appear to agree that compassion fatigue is an occupational hazard that mental health care professionals need to address (Figley, 2002; Merriman, 2015a).
Factors Associated With Compassion Fatigue
Many researchers have studied the relationships between compassion fatigue and various constructs, such as empathy, gender, mindfulness, support, and wellness (e.g., Beaumont, Durkin, Martin, & Carson, 2016; Caringi et al., 2016; Ray et al., 2013; Sprang, Clark, & Whitt-Woosley, 2007; Turgoose et al., 2017). Researchers conducted most of these studies among novice and veteran mental health professionals. Scant research among CITs exists. Our research attempts to fill this gap by exploring factors affecting CITs given their unique position as both students and emerging professionals. The following review of the literature supports the inclusion of predictor variables used in this study.
Empathy and Compassion Fatigue
One of the most widely studied concepts across various cultures is empathy, as it has been determined to be one of the major precipitants of compassion fatigue (Figley, 1995). However, findings in the literature regarding the association between compassion fatigue and empathy remain mixed (e.g., MacRitchie & Leibowitz, 2010; O’Brien & Haaga, 2015; Wagaman, Geiger, Shockley, & Segal, 2015). For instance, O’Brien and Haaga (2015) compared trait empathy and empathic accuracy with compassion fatigue after showing a videotaped trauma self-disclosure among therapist trainees (a combined group of advanced and novice graduate students) and non-therapists. The results indicated that there was no significant association between participants’ levels of compassion fatigue and empathy scores. However, MacRitchie and Leibowitz (2010) found a significant relationship between compassion fatigue and empathy after exploring the relation of these variables on trauma workers whose clients were survivors of violent crimes. The mixed results of these previous studies suggest further research is needed to understand better the relationship between empathy and compassion fatigue and how this relationship impacts counseling practice.
Supervisory Working Alliance and Compassion Fatigue
Although reviewed literature addressed studies suggesting supervision and support are related factors to compassion fatigue, research on this relationship is still insufficient. Kapoulitsas and Corcoran (2015) conducted a study and found that a positive supervisory relationship has a significant role in developing resilience and reducing compassion fatigue among counselors. Knight (2010) also found that students uncomfortable talking with their supervisor reported a higher risk for developing compassion fatigue. Additionally, organizational support appears to reduce compassion fatigue, whereas an absence of support increases practitioners’ and interns’ risk of developing compassion fatigue symptoms (Bride, Jones, & MacMaster, 2007). Given the intense need for support and guidance CITs need during their initial work with clients, it is expected that those students who do not actively work with their supervisors can struggle and be more vulnerable for compassion fatigue.
Wellness, Resilience, and Compassion Fatigue
Although counselors are encouraged to practice self-care activities to continue to enhance personal well-being (American Counseling Association [ACA], 2014; Coaston, 2017; H. L. Smith, Robinson, & Young, 2008), not all CITs can balance caring for self and others. When CITs do not receive training in the protective factors for compassion fatigue, they risk becoming more vulnerable to violating the ACA code of ethics (Merriman, 2015a; Merriman, 2015b). Kapoulitsas and Corcoran (2015) and Skovholt and Trotter-Mathison (2016) highlighted the importance of resilience and self-care activities as protective factors for compassion fatigue. Wood et al. (2017) evaluated the effectiveness of a mobile application called Provider Resilience to reduce compassion fatigue scores of mental health professionals. After a month of utilization, the results indicated that the application was effective in reducing compassion fatigue. Additionally, Lawson and Myers (2011) conducted a study with professional counselors to examine counselor wellness about compassion fatigue and found a negative correlation between total wellness scores and compassion fatigue scores. As CITs balance academic, family, and work demands, the probability of decreased wellness and a corresponding increase in compassion fatigue exists.
Compassion Fatigue Among CITs
Most CITs are often unable to master all counselor competencies (Rønnestad & Skovholt, 2013), and therefore they might not know how to deal with possible stressors and the emotional burden of their work (Star, 2013). Although they are learning counseling skills to provide the best care possible to clients, CITs may find themselves working with seriously troubled or traumatized clients without obtaining quality supervision and support (Skovholt & Trotter-Mathison, 2016). Lack of skills and resources increases the likelihood of CITs developing compassion fatigue (Merriman, 2015b). However, there is a lack of focus in compassion fatigue education on preparing CITs to manage compassion fatigue symptoms (Merriman, 2015a). Although scholars have examined compassion fatigue among counselors, there is still a dearth of studies investigating the level of compassion fatigue among CITs and addressing its protective factors within this population (Beaumont et al., 2016; Blount, Bjornsen, & Moore, 2018; Thompson et al., 2014). Subsequently, further research is needed to understand better potential protective factors that can be enhanced to offset the negative impact of compassion fatigue on CITs and the counseling process. Thus, with this study, we aimed at assessing the relationship between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue among CITs in the United States. To accomplish this goal, we sought to answer the following research questions: (1) What is the prevalence of compassion fatigue among CITs? and (2) Do empathy, supervisory working alliance, resilience, and wellness significantly predict levels of compassion fatigue among CITs?
Participants recruited for this study consisted of master’s-level counseling students who are at least 18 years of age and enrolled in an internship course in the United States through mostly professional listservs (e.g., Counselor Education and Supervision Network Listserv [CESNET-L], Texas Association for Counselor Education and Supervision Network Listserv [TACESNET-L], Counseling Graduate Student Network [COUNSGRADS]). Because of the impossibility of knowing how many individuals received the email invitation, we were unable to calculate and determine a response rate. Accordingly, a total of 114 CITs initially agreed to participate in this study. Before data analysis, we inspected the data set for possible entry errors and missing data. After the inspection, we excluded 28 participants from all subsequent data analyses resulting in the reduced sample of 86 CITs used to address our research questions. Overall, the sample consisted of 78 female (90.7%) and eight male (9.3%) participants, and the mean age of the participants was 32.89 years (SD = 9.72) with participants’ ages ranging between 21 and 62 years. Participants were from diverse ethnic and racial backgrounds, with the sample consisting of White (n = 48, 55.8%), Hispanic/Latino (n = 18, 20.9%), Black/African American (n = 12, 14.0%), and Asian (n = 5, 5.8%) CITs. Three participants (3.5%) listed their ethnicities as “other” when providing demographic information. Participants reported their program enrollment as follows: clinical mental health counseling program (n = 47, 54.7%); school counseling program (n = 23, 26.7%); marriage, couple, and family counseling program (n = 4, 4.7%); college counseling and student affairs program (n = 3, 3.5%); addiction counseling program (n = 2, 2.3%); and other programs (n = 7, 8.1%). Additionally, most of the participants (n = 73, 84.9%) reported enrollment in a CACREP-accredited program with the remaining participants (n = 13, 15.1%) enrolled in a non–CACREP-accredited program.
Upon receiving institutional review board approval, we recruited participants from different institutions with the primary researcher contacting professional colleagues at various departments to disseminate the online survey link to potential participants during the 2017 summer and fall semesters. We also recruited participants through professional listservs (e.g., CESNET-L, TACESNET-L, COUNSGRAD), with listserv participants being provided the same informed consent and survey link through a secure website. The survey completion process took approximately 15–20 minutes.
We used the following self-administered survey questionnaires and a separate demographic data sheet in our data collection.
Professional Quality of Life Scale (ProQOL). This scale is designed to measure the mental and emotional consequences of working with individuals who experienced trauma or painful events (Stamm, 2010). The ProQOL includes two main traits, Compassion Satisfaction (positive) and Compassion Fatigue (negative). Compassion Satisfaction is related to the joy individuals develop when they do their work well (Stamm, 2010). Compassion Fatigue consists of two subscales: Secondary Traumatic Stress (STS) and Burnout. Scholars have defined STS as an emotional state that occurs when an individual becomes upset or traumatized as a result of their exposure to victim experiences (Figley, 2002). The second part of Compassion Fatigue is Burnout, which is a multidimensional syndrome related to the social work environment. Burnout could be related to work overload, lack of control, insufficient rewards, unfairness, and value conflict at a workplace (Skovholt & Trotter-Mathison, 2016).
The ProQOL is a 30-item Likert-type self-report assessment with responses of never, rarely, sometimes, often, and very often for each item. A sample item is “I feel depressed because of the traumatic experiences of the people I [help].” This assessment has 10 questions per each of three main scales measuring separate constructs. However, the Compassion Fatigue scale includes two of these constructs, which are the Burnout and the STS scales. According to Stamm (2010), the ProQOL has good construct validity, as researchers have noted its efficacy in over 200 published articles. Finally, alpha coefficient values for the Burnout and STS scales were .75 and .81, respectively (Stamm, 2010), and are similar (.72 and .79) to the Cronbach’s alpha values from the current study presented in Table 1.
Descriptive Statistics of the Study Variables (N = 86)
|Supervisory Working Alliance
Note. BO = Burnout; STS = Secondary Traumatic Stress; CF = Client Focus; R = Rapport
Interpersonal Reactivity Index (IRI). Davis (1983) developed the IRI to measure the reactions of a person to other individuals’ observed experiences. The 28-item instrument has four subscales: Empathic Concern, Perspective Taking, Fantasy, and Personal Distress (Davis, 1983). Researchers report separate subscale scores, as a total score for the instrument has not been recommended (Davis, 1983). In this study, we only used the Empathic Concern subscale to collect data regarding empathy scores of CITs.
Davis (1983) described empathic concern as an emotional response, such as compassion and sympathy, to someone else in need. The 7-item subscale is a self-report assessment with a 5-point Likert-type scale, ranging from Does not describe me well to Describes me very well. A sample item is “I am often quite touched by things that I see happen.” An alpha coefficient of .77 has been reported for the Empathic Concern subscale (Péloquin & Lafontaine, 2010), while the Cronbach’s alpha value of the IRI in the current study was .80.
Supervisory Working Alliance Inventory: Trainee Form (SWAI-T). Efstation, Patton, and Kardash (1990) developed this inventory to measure supervisees’ perceptions about the effectiveness of the working relationship with their supervisors, and we used the SWAI-T to measure the construct of the supervisory working alliance. With a total of 19 items, the self-report assessment includes a 7-point Likert-type scale with responses ranging from almost never to almost always. A sample item is “When correcting my errors with the client, my supervisor offers alternative ways of intervening with the client.” The SWAI-T has two subscales—Client Focus and Rapport—and the Cronbach alpha coefficients of these scales were .77 and .90, respectively (Efstation et al., 1990). For the current study, we calculated Cronbach alpha values of .90 for the Client Focus subscale and .93 for the Rapport subscale. Because some researchers have found high correlations between these two subscales, they decided to combine them in their studies (e.g., Ganske, 2007; White & Queener, 2003). Therefore, in this study, after conducting a correlation analysis with the subscale scores, we also chose to combine subscales as the results of subscale scores were highly correlated.
Brief Resilience Scale (BRS). The BRS was developed to measure a person’s ability to recover from stress and cope with challenging situations (B. W. Smith et al., 2008). The BRS is used to measure the construct of resilience. As a 6-item self-report assessment, the BRS includes a 5-point Likert-type scale with responses ranging from strongly disagree to strongly agree. A sample item is “I usually come through difficult times with little trouble.” B. W. Smith and colleagues (2008) reported that the Cronbach’s alpha values of the BRS range from .80 to .91, and we calculated a Cronbach alpha of .89 for the current study.
Flourishing Scale (FS). The FS was designed to measure individuals’ self-perceived success in areas like optimism and relationships (Diener et al., 2010) and used to measure the construct of wellness in this study. The FS is an 8-item self-report assessment with a 7-point Likert-type scale with responses ranging from strongly disagree to strongly agree (Diener et al., 2010). A sample item is “I lead a purposeful and meaningful life.” Diener and colleagues (2010) reported moderately high reliability with a .87 Cronbach’s alpha coefficient, and in the current study, the FS had a Cronbach alpha of .86.
Statistical power analysis. We used an a priori type of the G*Power to set the minimum number of participants needed to detect statistical power for this research design. Based on an alpha of .05, a power level of .90, and four predictors (Faul, Erdfelder, Buchner, & Lang, 2009), the computation results suggested that a minimum of 73 participants was required to detect statistical significance with at least a moderate size effect (.15). We had 86 participants, suggesting adequate power.
Preliminary analyses. We analyzed all data using the Statistical Package for the Social Sciences, Version 20 (SPSS; IBM Corporation, 2011). Before addressing our stated research questions, we cleaned the dataset and addressed missing data. We did not observe any pattern between missing data points. Therefore, the type of missing data was completely random, which was addressed using the series of mean function within the SPSS. Next, we calculated descriptive statistics and alpha coefficients for each scale used in the study (see Table 1). Before performing hierarchical regression analyses, we tested all associated model assumptions. First, we examined study variables based on their types and concluded each utilized a continuous scale. We then assessed normality with the Shapiro-Wilk test of normality (W > .05), indicating data was normally distributed for the dependent variable. To identify outliers, we examined boxplots. Although there were a few mild outliers, no extreme scores were detected. We assessed linearity and homoscedasticity through inspection of standardized residual plots. To assess for the assumption of multicollinearity, we examined the correlation matrix of study variables to determine if any correlated highly. According to Field (2013), correlations above .80 are considered high and may indicate the presence of multicollinearity. In the present study, none of the correlation coefficients were above .50 (see Table 2). Collectively, these findings indicated no evidence suggesting any of the model assumptions had been violated. As a result, the dataset was deemed appropriate for analysis using a hierarchical regression design.
Primary analysis. Descriptive statistics were calculated to organize the data by producing means, mode, median, standard deviations, and minimum and maximum scores for the study variables (Field, 2013). Individually, we reviewed descriptive statistics for the compassion fatigue variable, and results were reported to address the first research question. Next, we performed a three-step hierarchical linear regression to address the second research question.
Intercorrelations for Scores on the Study Variables
Note. N = 86; ProQOL = Professional Quality of Life (Compassion Fatigue [CF] subscale score is presented); IRI = Interpersonal Reactivity Index (Empathic Concern [EC] subscale score is presented); SWAI-T = Supervisory Working Alliance Inventory: Trainee Form; BRS = Brief Resilience Scale; FS = Flourishing Scale.
*p < .05. **p < .01.
Compassion fatigue scores of CITs represent the sum of scores of all items on the STS and Burnout subscales. According to the ProQOL administration manual (Stamm, 2010), individuals scoring below 22 may indicate little or no issues with Burnout and STS, while scores between 23 and 41 indicate moderate levels of Burnout and STS, and scores above 42 indicate higher levels of Burnout and STS. For this sample, participants’ Burnout scores ranged from 12 to 32 with a mean of 21.34 (SD = 4.38), and STS scores ranged from 10 to 38 with a mean of 20.14 (SD = 4.96). These results indicated a low risk of both Burnout and STS among CITs.
To address the second research question, we performed a three-step hierarchical linear regression analysis. With this analysis, we aimed to assess the association between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue. We chose to implement a hierarchical multiple regression analysis because scholars previously have highlighted the essential relationship between empathy, supervision, and compassion fatigue (Figley, 2002; MacRitchie & Leibowitz, 2010). In the first step, empathy scores entered the model as a predictor variable, as Figley (1995) stated that empathy is one of the main factors contributing to compassion fatigue. However, among this sample, we found that empathy was not a significant predictor of compassion fatigue: F(1, 84) = .2, p = .66 , R2 = .002 (adjusted R2 = -.01). Then, we added supervisory working alliance scores to the model in the second step, as both Knight (2010) and Miller and Sprang (2017) emphasized the importance of supervisory support for mental health practitioners. Results revealed that the supervisory working alliance variable also was not a significant predictor of compassion fatigue: F(2, 83) = .16, p = .85, R2 = .004 (adjusted R2 = -.02). In the third step, resilience and wellness scores were entered into the model to determine whether these variables significantly improved the amount of explained variance in compassion fatigue. Results showed that this combination of variables significantly predicted 26% of the variance in compassion fatigue: F(4, 81) = 8.57, p < .001, R2 = .30. Therefore, it was concluded that CITs with greater wellness and resilience reported developing less compassion fatigue (see Table 3).
Hierarchical Regression Analysis Results for Variables Predicting Compassion Fatigue
Note. SWA = Supervisory Working Alliance
*p < .05.
In this study, CITs reported having a low risk of compassion fatigue. When we examined the Burnout and STS scores separately, the main contributors of compassion fatigue (Stamm, 2010), both subscale scores indicated participants having a low risk for STS and Burnout. This finding is similar to results found by Beaumont and colleagues (2016) in their study of compassion fatigue, burnout, self-compassion, and well-being relationships among student counselors and student cognitive behavioral psychotherapists. According to their research findings, a total of 54 student participants reported high scores on self-compassion and well-being and reported less compassion fatigue and burnout (Beaumont et al., 2016).
One of the goals of this study was to seek understanding of whether wellness and resilience explain a statistically significant amount of variance in compassion fatigue among CITs after accounting for empathy and supervisory working alliance. The results indicated that empathy and supervisory working alliance were not significant predictors of compassion fatigue. Regarding empathy and compassion fatigue relation results, the findings of this study did not support Figley’s (1995) assumption of empathy as one of the main contributors to compassion fatigue. This result also is inconsistent with Wagaman and colleagues’ (2015) results indicating a significant association between empathy and compassion fatigue among social workers. However, current results aligned with those studies that found no correlation between empathy and compassion fatigue (e.g., O’Brien & Haaga, 2015; Thomas & Otis, 2010). An explanation of the variability between this inquiry and previous studies might lie with the difference between participants’ field of study and measurement differences. Also, none of the previous studies used CITs solely as their sample, nor used a similar way to measure the construct of empathy. Additionally, CITs would have less experience working with clients compared to experienced counselors, and thus less time for feelings of compassion fatigue to build.
Although scholars addressed the importance of supervision and supervisory working alliance to help prevent compassion fatigue (Kapoulitsas & Corcoran, 2015; Merriman, 2015a), this study’s results indicated supervisory working alliance was not a significant predictor of compassion fatigue among CITs. Like current results, Ivicic and Motta (2017) and Williams, Helm, and Clemens (2012) found no statistically significant association between supervisory working alliance and compassion fatigue among mental health practitioners. It is noteworthy that these studies highlighting the importance of supervision and the supervisory relationship are qualitative in design, and participants did not consist solely of CITs. Additionally, their results emphasized the importance of supervision as support to counter the negative impact of trauma exposure (Kapoulitsas & Corcoran, 2015; Ling, Hunter, & Maple, 2014). According to the current study results, CITs did not report experiencing a high level of compassion fatigue. This finding could be interpreted as CITs not yet feeling the need for supervisory support to help with compassion fatigue.
Results also indicated that resilience and wellness were significant predictors of compassion fatigue among CITs. In other words, when reflecting on both the regression and correlation results, CITs with greater resilience and wellness reported lower scores of compassion fatigue and these results were consistent with Tosone, Minami, Bettmann, and Jasperson’s (2010) research findings. Regarding a wellness and compassion fatigue relationship, Beaumont and colleagues (2016) conducted a study with student counselors and student cognitive behavioral psychotherapists. The results of Beaumont et al.’s study revealed that individuals with high scores of self-compassion and well-being reported having less compassion fatigue and burnout. Thomas and Morris (2017) also highlighted the significance of self-care and well-being not only for preventing and helping to manage the potentially damaging impact of practice, but also for facilitating the counselor’s personal and professional growth.
Implications for Counselor Educators and Supervisors
The research findings provide data-driven results regarding compassion fatigue among CITs that have meaningful implications for counselor educators and supervisors. Present study results revealed that CITs indicated experiencing a low risk of compassion fatigue. However, raising awareness on this issue may still help CITs as a preventative measure to cope with possible compassion fatigue experience in the future. To address this issue, counselor educators may consider raising awareness on this topic by reviewing current counseling program curricula to add discussion questions related to compassion fatigue and its empirically predictive factors—wellness and resilience. Roach and Young (2007) stated that students in counseling programs reported group counseling, counseling techniques, legal and ethical issues, practicum, and wellness courses as contributing most to their knowledge and skills regarding wellness. Therefore, counselor educators might use different assignments, including group discussions, projects, and role-playing exercises, to open a discussion about the compassion fatigue phenomenon and the relation with its predictive factors and these courses. Counselor educators may also use the ProQOL scale as an assignment in an assessment and testing course to inform CITs about how to use this instrument as a self-monitoring aid. For example, professional counselors may feel overwhelmed because of working with trauma survivors after graduation and start noticing compassion fatigue symptoms in themselves. These individuals may self-administer the ProQOL scale to determine whether they have developed compassion fatigue. Additionally, in a practicum or an internship course, CITs may fill out the ProQOL as part of their continuing personal wellness plan by comparing personal results over time and sharing their thoughts and reflections about the results.
Supervisors need to find ways to raise awareness of compassion fatigue and its protective factors with CITs. For instance, during internship experience, supervisors may develop a site training including compassion fatigue awareness for CITs, as CITs should be prepared for the possible emotional and psychological consequences in working with trauma survivors. Student counselors also should be encouraged to advocate for themselves when they notice symptoms of compassion fatigue. Supervisors might consider the administration of the ProQOL scale regularly to assess both organizational and individual risks (Newell & MacNeil, 2010). Additionally, supervisors can use the ProQOL scale with their supervisees to start a conversation about compassion fatigue. Although the ProQOL is not a diagnostic test, the 30-item self-report scale can be utilized readily as a conversation starter in supervision sessions.
The results suggested that empathy and supervisory working alliance did not predict CITs’ compassion fatigue level. However, wellness and resilience are significantly related to contributing to it. Therefore, both counselor educators and supervisors might consider enhancing CITs’ resilience and wellness a worthwhile endeavor. For example, Miller and Sprang (2017) developed a component-based practice and supervision model to reduce compassion fatigue for use in training, supervision, and clinical practice. A tool like this one can be added to existing training curricula and supervision practice to improve CITs’ resilience and wellness.
The results of this study aim to provide greater clarity regarding the predictive factors of compassion fatigue among CITs. However, interpretation of results should take into consideration the limitations that emerged because of uncontrollable influences and choices we made. The study was limited in its ability to represent all CITs throughout the United States, as we utilized a convenience sampling approach. Additionally, we gathered data through self-report questionnaires, which introduce the possibility of response bias in the findings. Although we assumed participants answered each question honestly, they might not have been honest in their responses because of the fear of being perceived as weak or less competent. It is important to note that being in an internship class might also increase participants’ interest in the profession as they currently are engaged in the practice of counseling. Therefore, participants might have had a higher level of enthusiasm and reported less compassion fatigue. Also, individuals who suffer from compassion fatigue might have preferred not to respond to these items. Finally, although participants were enrolled in an internship class, each participant may have different numbers of hours of client experience.
Future Directions for Research
Additional research should be conducted to expand and clarify the current research findings of compassion fatigue among CITs. A phenomenological study using a qualitative research method is recommended to expand the findings of this current study. Future researchers may use the ProQOL scale to assess CITs’ level of compassion fatigue and then conduct interviews with the volunteer participants reporting a higher level of compassion fatigue to better understand CITs’ experience with compassion fatigue and its contributing factors. The data collected through a qualitative study may provide greater insight into the phenomenon of compassion fatigue among CITs. Additionally, researchers can replicate the present study with early-career counselors who have recently graduated, because of the noted intensity of those first years after graduation (Skovholt & Trotter-Mathison, 2016). Therefore, future researchers exploring novice counselors’ experiences with compassion fatigue will help counselor educators and supervisors better understand when counselors may start developing compassion fatigue symptoms, as well as how they cope with the symptoms.
CITs may struggle when they continuously hear painful stories of clients because of a lack of experience, skillset, or support (Skovholt & Trotter-Mathison, 2016). Researchers have described this experience as compassion fatigue. With this study, we aimed to provide a better understanding of the predictive factors of compassion fatigue among CITs. Using data-driven research results to determine ways to work with CITs on compassion fatigue and its predictive factors can be beneficial in preventing compassion fatigue symptoms from an early onset. CITs may take precautionary measures to ensure they remain enthusiastic and energized by the work they do. Further, implications of the current study may help CITs start their professional careers better prepared to provide their clients with the optimal care needed throughout the counseling relationship by minimizing compassion fatigue.
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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Nesime Can is an instructor at Ankara University in Turkey. Joshua C. Watson, NCC, is a professor and department chair at Texas A&M University–Corpus Christi. Correspondence can be addressed to Nesime Can, Ankara University Faculty of Educational Sciences, Department of Educational Sciences, Program of Counseling and Guidance, Office 3111, Çankaya, Ankara, Turkey 06590, email@example.com.
Yvette Saliba, Sejal Barden
Occupational stress is a top source of stress for over 65% of Americans due to extended hours in the workplace. Recent changes in health care have encouraged employers to build workplace wellness programs to improve physical and mental health for employees to mitigate the effects of occupational stress. Wellness programs focus on either disease management; treating chronic illnesses, such as hypertension and diabetes; lifestyle management; or preventing chronic illnesses through health promotion. This manuscript provides an overview of recent changes in health care and describes a conceptual framework, Steps to Better Health (S2BH), that counselors can use in workplace wellness programs. S2BH is an 8-week psychoeducational group based on the combination of motivational interviewing (MI) and the transtheoretical model of change (TTM).
Keywords: wellness, health care, workplace, stress, Steps to Better Health
Health and wellness are two concepts that have captured the attention of people throughout history. From Greek mythology to modern times, the idea of well-being has permeated society (Myers & Sweeney, 2007). Today, with the Patient Protection and Affordable Care Act (PPACA), health care is moving away from a disease treatment model and embracing a disease prevention model (PPACA, 2010). Although individuals typically do not invest in preventive health measures, many businesses and companies are eager to improve their health care programs for employees (Willis Towers Watson, 2017). These changes in health care are relevant to mental health providers, as a new focus on prevention has created opportunities for counselors to help effect lasting health changes among employees. Therefore, to fit into this paradigm shift, professional counseling should be strongly connected to prevention and wellness (Granello, 2013). This article discusses the changes in health care models, how those changes are creating spaces for mental health counselors to fill and implications for the counseling profession.
The Changing Landscape of Health Care
In 2015, the Kaiser Family Foundation released a report highlighting the rising cost of health care expenditures from 1960 to 2013. This report indicated that health care costs, which include total costs for hospital visits, physicians and clinics, as well as prescription medications, have risen from 27.4 billion dollars to over $2 trillion (Kaiser Family Foundation, 2015). Due in part to increases in the cost of health care and health insurance, the PPACA was passed into federal law in 2010. Mandates of the PPACA include: (a) preventing the denial of coverage for pre-existing conditions; (b) strengthening community health centers; (c) decreasing health disparities; (d) promoting integrated health systems; (e) connecting physician payments to the quality rather than the quantity of care provided; and (f) lowering long-term costs by providing free and more comprehensive preventive care (U.S. Department of Health and Human Services, Health Care, 2016). In a White House memo sent out during National Public Health Week in 2014, President Obama stated, “my administration is supporting efforts across our country to improve public health and shift the focus from sickness and disease to wellness and prevention” (Obama, 2014, p. 1).
This shift is clearly seen in the PPACA. Section 4001 of the PPACA, entitled “Modernizing Disease Prevention and Public Health Systems,” discusses ways in which health prevention should be carried out within the public sector (PPACA, 2010). This portion of the law includes a taskforce team that would: (a) evaluate wellness programs in 2013; (b) create the Prevention and Public Health Fund to distribute money to worksites establishing wellness programs; (c) further the education of health and wellness promotion; and (d) report on measures enacted that address lifestyle behavior modification (PPACA, 2010). Lifestyle behavior modification is defined as activities that include “smoking cessation, proper nutrition, appropriate exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings” (PPACA, 2010, p. 422). In other words, initiatives from the federal government highlight the emphasis on prevention in both community and clinical health venues and extend this focus by supporting research into workplace wellness initiatives (Anderko et al., 2012). Though the PPACA encourages workplace wellness programs, many employers see the benefits to their employees even without federal regulations. In a recent survey, employers indicated they are still committed to better workplace wellness programs despite the unknown future of the PPACA (Willis Towers Watson, 2017). One primary motivator behind these programs is a reduction of employee stress through health promotion.
Health Promotion in the Workplace
According to the 2015 Bureau of Labor and Statistics report, Americans spent 8.8 hours a day at work or doing work-related activities (U.S. Department of Labor, 2016). Therefore, it can be estimated that Americans spend much of their lives in workplace settings, which can lead to occupation-related stress. In 2012, the American Psychological Association’s (APA) Stress in America Survey revealed that 65% of Americans reported work as a top source of stress (APA, 2016). Stress can affect a person’s emotional state, and it also can weaken the body’s ability to regulate itself after a stressful experience, which can eventually cause detrimental health consequences (Galla, O’Reilly, Kitil, Smalley, & Black, 2015). For example, the effects of chronic stress have been shown to lead to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016). As a result, many individuals have resorted to maladaptive ways of coping with stress, highlighting the need for bringing stress management skills to the workplace (Galla et al., 2015). In addition, the World Health Organization has stated that health promotion in the workplace (promoting aspects of physical and emotional wellness) is beneficial in combating work-related stress (Jarman, Martin, Venn, Otahal, & Sanderson, 2015).
Finding ways to help employees manage their stress through health promotion in the workplace is typically conducted through workplace wellness programs, which include both lifestyle and disease management programs (Caloyeras, Hangsheng, Exum, Broderick, & Mattke, 2014; Kaspin, Gorman, & Miller, 2013; Mattke et al., 2013). Promoting positive health habits among employees maintains affordable health coverage and increases worker productivity (Anderko et al., 2012; Parkinson, Peele, Keyser, Liu, & Doyle, 2014; Shapiro & Moseley, 2013). Most workplace wellness programs focus on disease management, treating chronic illnesses such as diabetes and hypertension. Disease management programs also typically utilize health care professionals, such as nurses, to conduct face-to-face meetings or telephone consultations (Caloyeras et al., 2014). Conversely, lifestyle management programs prevent chronic illnesses by: (a) reducing stress; (b) lowering weight; (c) encouraging exercise; (d) promoting smoking cessation; and (e) fostering overall well-being (Caloyeras et al., 2014; Kaspin et al., 2013; Mattke et al., 2013).
Johnson & Johnson was an early pioneer in the creation and promotion of workplace wellness programs. In the 1970s, the company implemented a wellness program for employees called Live for Life (Ozminkowski et al., 2002). In 1993, this program was modified to integrate the following additional services: (a) employee health; (b) occupational medicine; (c) health promotion; (d) disability management; and (e) an employee assistance program. A modified program was rebranded with a new title: The Johnson & Johnson Health & Wellness Program (Ozminkowski et al., 2002). At the time of the program analysis, Johnson & Johnson employed approximately 40,000 people in the United States, 90% of whom participated in their wellness program. The program was evaluated by comparing outpatient doctor visits, hospital inpatient stays and mental health visits over the course of four years as compared to three years prior to the start of the wellness program. The worksite wellness program resulted in significant annual savings per employee/per year. On average, the study reported $45.17 savings for each outpatient visit, $119.67 per inpatient stays and $70.69 for mental health visits. In sum, Johnson & Johnson reported over $8 million in annual savings (Kaspin et al., 2013; Ozminkowski et al., 2002), creating a model wellness program that has been replicated in other organizations to varying degrees.
In contrast, PepsiCo offered a program in 2004 that did not produce similar results. Over 55,000 employees participated in a 3-year study, and it was determined that while costs were high in the initial year, it was the disease management portion of the program that lowered overall medical expenses by the third year (Liu et al., 2013). The disease management program was six to nine months in length and involved regular phone calls with a nurse for 15 to 25 minutes (Caloyeras et al., 2014). The program focused primarily on conditions such as asthma, coronary artery disease, congestive heart failure, hypertension and strokes (Caloyeras et al., 2014). Conversely, the lifestyle management portion of the program, which focused on weight management, nutrition management, fitness, stress management and smoking cessation, was described simply as involving a “series of telephonic calls with a wellness coach over a six-month period” (Caloyeras et al., 2014, p. 125). Training to become a wellness coach varies widely, ranging from a few days to 6 months. Training typically requires an associate degree and 18 weeks of classes conducted over the telephone or four full days of training in topics that include: (a) growth-promoting relationships; (b) expressing compassion; and (c) eliciting motivation to overcome ambivalence (Wellcoaches, 2016). The lack of sustainable changes in lifestyle wellness programs may be due to the variation and brevity of training for wellness coaches.
Hospitals have started employee wellness programs to lower employee health insurance costs, support mental health, and recruit and retain quality employees (Caloyeras et al., 2014; Hochart & Lang, 2011; Liu et al., 2013; Parkinson et al., 2014). Ironically, while the health care system is designed to help patients achieve good health, it often comes at the price of high stress levels and poor health for the employees (Chang, Hancock, Johnson, Daly, & Jackson, 2005; McClafferty & Brown, 2014; Smith, 2014). In fact, hospital employees tend to exhibit poorer health than other types of employees, which results in hospitals having the highest health care costs among employment sectors in the United States (Parkinson et al., 2014). As a result, some hospitals, such as the University of Pittsburgh Medical Center, are introducing the idea of employee wellness programs. In 2005, the University of Pittsburgh Medical Center utilized a prepackaged wellness program called MyHealth—a program that included both lifestyle and disease management components (Parkinson et al., 2014). Based on the number of requirements an employee met and activities he or she engaged in, the program provided credit that could be used to lower insurance deductibles (Parkinson et al., 2014). MyHealth consisted of online education materials, self-help tools, telephonic health coaching and support groups for lifestyle issues such as smoking cessation, depression, and emotional health and stress issues (Parkinson et al., 2014). Over a 5-year period, overall health care costs were lowered, but again, savings were attributed to the disease management portion of the program and not the lifestyle management portion (Caloyeras et al., 2014). Although there has been moderate success with wellness programs, the inclusion of counselors could make these programs more successful.
Need for Counselors in Wellness Programs
Changes in health care and increases in worksite wellness programs have created footholds for trained mental health professionals. As evidenced in the cases above, health care professionals, rather than mental health professionals, are facilitating lifestyle wellness programs. This is unfortunate, as professional counselors are trained in the skills of rapport building, demonstrating empathy and helping others achieve their goals. To build upon counselors’ inherent training and strengths may reduce the need for additional support and behavior change training. Utilizing counselors may result in stronger program implementation and cost savings for companies (Groeneveld, Proper, Absalah, van der Beek, and van Mechelen, 2011). Furthermore, although there have been some promising results and modest savings due to wellness programs, the variability in the content of wellness programs ranges widely. Therefore, it is proposed that having a program designed and led by counselors may have the potential to create larger savings for the lifestyle management portion of worksite wellness programs. With counselors utilizing their skills and coupling these techniques with aspects of motivational interviewing (MI) and the transtheoretical model of change (TTM), they could strengthen the lifestyle management portion of wellness programs and build on the foundation of wellness in counseling. To this end, we propose a psychoeducational lifestyle management conceptual framework that combines both MI and the TTM in an 8-week program, entitled Steps to Better Health (S2BH), which is described in the following section.
Components of S2BH
MI is an approach that helps individuals motivate themselves to pursue the changes that they seek. The founders of MI, Miller and Rollnick (2013), defined MI as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12). More precisely, MI is about skillfully arranging conversations so that people talk themselves into changing (Miller & Rollnick, 2013). Further, MI has been positively correlated with stress reduction, medication adherence, diet change and exercise participation (Rollnick, Miller, & Butler, 2008). Miller and Rollnick (2013) asserted that people from all backgrounds could be trained to use the tools of MI; however, they emphasize that MI is not simply a collection of techniques (Miller & Rollnick, 2013). Rather, MI should be applied in a context that is characterized by client-counselor collaboration, client independence, and empowering clients to find and use their own resources for change (Young, Gutierrez, & Hagedorn, 2012). In addition to MI, the proposed wellness program integrates the TTM, an evidence-based model for change, and research on effective group work.
The TTM was developed by Prochaska and DiClemente (1982) to facilitate behavioral changes for individuals (Campbell, Eichhorn, Early, Caraccioli, & Greeley, 2012). The TTM consists of five stages of change individuals experience when changing behavior. The five stages are: (a) pre-contemplative (not thinking about change); (b) contemplative (thinking about change); (c) preparation (taking steps to begin change); (d) action (making the change); and (e) maintenance (creating a habit of new change; Shinitzky & Kub, 2001).
Prochaska et al. (2008) reviewed employee health promotion interventions, and results demonstrated that both MI and the TTM individually can lead to effective change. Participants (N = 1400) at a major medical university were assigned to three treatment groups: brief health risk intervention (BHRI) only (n = 433), online TTM-tailored treatment (n = 504), and an MI treatment group (n = 433; Prochaska et al., 2008). The results of the study showed that both the MI and TTM treatment groups had more individuals participating in the action stage for exercise and indicated better management of stress along with less health risk behaviors in 6 months than the BHRI only group (Prochaska et al., 2008). This study suggests that if both MI and TTM are effective separately, then combining them could lead to further success. Additionally, utilizing this combination within the framework of a psychoeducational group for a workplace would create efficiency.
Psychoeducational group work is ideal for a wellness program as it is a “hybrid of an academic course and counseling session” (Brown, 2011, p. 8). This format allows participants to feel as though they are attending a class, which can help them focus on learning and implementing a specific task without the potential stigma of therapy. For working professionals who may not feel the need to participate in traditional counseling, a psychoeducational group provides opportunity for discussions and activities in which individuals can practice various wellness techniques in a safe setting. Additionally, groups can be more cost-effective for businesses and organizations, as a number of individuals can simultaneously accomplish goals in a shared timeframe.
For many wellness programs, the results have been mixed due to expensive training and inadequate application of behavior change principles. For the lifestyle management portion of these wellness programs to be successful, a stronger framework would need to be implemented along with the use of professionally trained counselors. Therefore, a conceptual framework that counselors can consider adapting for a wellness lifestyle management program is proposed. The intention is to emphasize critical theoretical components while integrating practical ideas for counselors to build upon and adapt into their own lifestyle and health management programs.
The proposed intervention of S2BH is an 8-week pyschoeducational group that incorporates aspects of both MI and the TTM. Each session consists of a short lesson about a concept related to change followed by a discussion that progressively moves each participant toward making the decision to change and successfully enacting those changes. Devoting 1 hour per week over the span of 8 weeks would yield overall balance and wellness among employees, leading to higher work performance and lower absenteeism (Vitality Institute, 2014). In addition to group sessions, the counselor should be available for optional one-on-one follow-up sessions, up to two times after the initial 8 weeks, ideally at the employer’s expense. These sessions would provide the opportunity for employees to address specific wellness concerns to help maintain changes. For demonstration purposes, below is a brief case example that demonstrates how S2BH could be utilized. In addition, Table 1 contains an overview of the program.
Polly, a 46-year-old oncology nurse for 20 years, and Amelia, a 35-year-old oncology nurse for 9 years, work at Metro Hospital, a 2,000-bed acute care medical facility located in a busy downtown area. Both Polly and Amelia were frustrated about their workloads and felt burned out because of job stressors. They were both interested in joining the S2BH group, as it would give them more points in Metro’s HealthyYou! Campaign. These additional points could later be translated into monetary bonuses to encourage employee participation. After gaining permission from their nurse manager to be part of the S2BH group, both women joined seven other nurses from different floors once a week for an hour during their lunch break. Both Polly and Amelia completed physicals as a part of the campaign, and despite weight and blood pressure issues, neither of the physicals for both women showed severe health concerns.
During their first meeting, Polly shared feeling fatigued and believing that her lack of exercise played a part in that. Amelia stated that though she managed to walk once a week, she still felt lethargic both emotionally and physically, but was not sure why. During this first group, the counselor utilized one of the central principles of MI, which reflects listening skills to express empathy and genuine caring for the nurses. To close the group, everyone received the S2BH Wellness Primer Worksheet as homework.
Suggested Curriculum for Steps to Better Health
Activities in Session
Week 1: Rapport Building and Therapeutic Alliance
|Counselor will welcome the group and explain the weekly format, with emphasis on goal attainment.
||Participants will be encouraged to share work-related stressors and wellness goals.
||A worksheet will be provided for participants to outline wellness goals, steps needed to achieve goals and identification of stressors.
|Participants will explore reasons for change and discuss the homework from the previous session.
||Participants will discuss potential pitfalls and necessary supports for successful change.
||Participants will identify what problems they encountered with their last change attempts.
The Stages of Change
|Counselor will give lesson on TTM, focusing on the stages of change.
||Participants will identify which stage of change they are in and work to develop stage-matched interventions.
||Participants will write down the advantages and disadvantages of achieving their wellness goal(s).
|Counselor will lead a discussion on ambivalence (Miller & Rollnick, 2013; Shinitzky & Kub, 2001).
||Participants will discuss benefits and costs of not changing behavior.
||Each participant will identify one to two new habits as they move toward their wellness goal(s).
|Counselor will discuss how participants can create new habits.
||Using homework, members will identify cues/routines/rewards for each new habit identified (Duhigg, 2012).
||Each participant will bring to the next session a brief update on their wellness goal(s).
Reframing & Risk Assessments
|Participants will discuss triggers and potential tactics to adhere to personal goals.
||Participants will identify and isolate potential triggers and solutions for the individual.
||Participants will identify stressors from work and life that could jeopardize wellness goal(s).
|Participants will discuss stress and ways to enhance coping skills (e.g., emotion-based and action-based).
||Participants will use homework to identify appropriate coping skills for each stressor.
||Participants will use one of the identified coping skills over the next week.
|Participants will discuss how to stay motivated and engaged with wellness plans.
||Participants will discuss achievements followed by a termination activity.
||No homework assigned.
Polly and Amelia came back to the second group with their S2BH Wellness Primer Worksheet results and were a little hesitant to begin discussing their results. After a few other members shared, Polly stated that the wellness primer made her more aware of her lack of exercise. Amelia then shared that this was the first time she had sat down and reflected on her health and well-being, and though she was not sure it was necessarily helpful, she was willing to try anything to stop feeling “blah.” Following the discussion on the wellness primer, group members worked on developing a wellness plan for the areas they wanted to improve. To close the session, the counselor discussed with the members ways to begin working on their goals in incremental steps and noted different ways they had started addressing those steps.
After learning about the stages of change from the TTM in the third session, Polly was animated about which stage she was on in relation to her goal of exercising more. She shared that she had been stuck on the contemplative stage of change for more years than she could count. She stated that she wanted to lose weight but could not seem to motivate herself to walk before her shift started.
Amelia stated that she wanted to eat better and classified herself as being in the pre-contemplative stage of change. She reported that she needed to eat better because she relied too often on caffeine and sugary foods to keep her going throughout the work day. Several of the group members expressed hope in knowing that they were not just “being lazy,” but were in a process of change. Amelia stated that just knowing that gave her a boost of energy.
After checking in during the fourth session and finding out where everyone was with their goals, the counselor led a discussion on the MI concept of ambivalence. Polly found this a little challenging, as she just wanted to list the pros and cons of her new health goals: exercising and eating better. Once she understood that she was to list both the benefits and costs of continuing her current behavior versus enacting her new health goal, she became more involved in the activity. As a result, Polly listed some pros of walking in the morning as being “it centers me as I release some of the frustration from the day before,” and “I use this time to organize my mind for the upcoming tasks for the day.” Amelia stated that some of her cons for not changing her behavior included “crashing hard around 4 p.m. in the afternoon” and “losing focus when working with patients.”
For the fifth session, a discussion centered around Duhigg’s (2012) book, The Power of Habit: Why We Do What We Do in Life and Business, and how members could apply the principle of cue, reward and routine to help them achieve their goals. Polly stated that she started putting her walking shoes out with her exercise clothes so that she could immediately see them when she woke up (cue). She would play her favorite podcast while walking (routine), and reward herself with a small low-calorie pastry for breakfast (reward). Amelia stated that she started to place almonds and other energy-boosting snacks at the nurses’ station so she could easily see them (cue), then would snack on those items while talking with colleagues (routine). As a result, she felt her energy lasting longer throughout the day (reward).
The nurses enjoyed reframing their previous “relapses” in the sixth session. Amelia reported that she was aware it was normal to move back and forth between the stages and that this knowledge alleviated concerns about failure. The group had a lively discussion about what triggers or pitfalls stood in their way and what places or things they should avoid as a result. For example, Polly stated that if she hit the “snooze button,” she would stay in bed and forgo her walk. Realizing this, she opted to place her alarm clock across the room so that she would have to get out of bed to turn off the alarm.
The seventh session on stressors became more emotional than anticipated as many of the nurses talked about their work and the unique stress they experience when taking care of ill and terminally ill patients. The group members talked about their thoughts and feelings and supported one another during this session. As a result, a spontaneous sharing of how nurses deal with the grief of losing patients occurred. Amelia shared that she had recently decided to join Team in Training for the Leukemia and Lymphoma Society and train for a half marathon in memory of one of her younger patients. She stated that letting the family know and beginning to raise money for research in this area was helping her to positively channel her grief. As a result of this discussion, several of the nurses stated that they left the group with hope, connectivity, and ideas for channeling their grief and stress.
The final session of the group focused on closure. Amelia shared that although she was initially dubious about the group, as a result of her sharing and the small changes she was making with her snacking, she was not feeling as “blah” anymore. Polly also shared that while she had not lost weight yet, she felt more motivated to continue walking and noticed that she felt more positive about walking.
Changes in health care have increased job opportunities in health care for counselors. The PPACA allows counselors the opportunity to expand their background of wellness while capitalizing on preventive health care initiatives (Barden, Conley, & Young, 2015; Granello & Witmer, 2013). With the interrelatedness between physical and mental health, counselors are ideally positioned to help clients achieve their wellness goals. Connections between physical activity and psychological well-being are well established, as are the potential benefits of improved coping with stress and adversity (Focht & Lewis, 2013). Because chronic stress has been shown to contribute to obesity and metabolic diseases (Razzoli & Bartolomucci, 2016), helping employees improve their coping skills can lead to adaptive ways of dealing with stress, which ultimately impacts chronic health conditions. To better manage occupational stress, counselors can fill the need for bringing stress management skills to the workplace (Galla et al., 2015).
In addition, wellness programs provide the ability for counselors to research their contributions to workplace wellness programs, thereby providing an opportunity to study counselor effectiveness. Research has shown that using health care professionals in disease management portions of wellness programs can lower costs. The focus of this manuscript has been to describe a framework for counselors to facilitate lifestyle management programs in corporate settings. Considerable sponsored research opportunities also are available, especially for worksite wellness programs targeted to underserved populations (U.S. Department of Health and Human Services Office of Minority Health, 2016).
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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Yvette Saliba, NCC, is a doctoral student at the University of Central Florida. Sejal Barden, NCC, is an Associate Professor at the University of Central Florida. Correspondence can be addressed to Yvette Saliba, 851 South State Road 434, Suite #1070-170, Altamonte Springs, FL 32714, firstname.lastname@example.org.
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, 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).
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.
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.
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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Ashley J. Blount, Dalena Dillman Taylor, Glenn W. Lambie, Arami Nika Anwell
Wellness is an integral component of the counseling profession and is included in ethical codes, suggestions for practice and codes of conduct throughout the helping professions. Limited researchers have examined wellness in counseling supervision and, more specifically, clinical mental health supervisors’ experiences with their supervisees’ levels of wellness. Therefore, the purpose of this phenomenological qualitative research was to investigate experienced clinical supervisors’ (N = 6) perceptions of their supervisees’ wellness. Five emergent themes from the data included: (a) intentionality, (b) self-care, (c) humanness, (d) support, and (e) wellness identity. As counselors are at risk of burnout and unwellness because of the nature of their job (e.g., frequent encounters with difficult and challenging client life occurrences), research and education about wellness practices in the supervisory population are warranted.
Keywords: supervision, wellness, unwellness, phenomenological qualitative research, helping professions
Wellness is an integral component of the counseling profession (Myers & Sweeney, 2004; Witmer, 1985) and is included in ethical codes, suggestions for practice and codes of conduct throughout the helping professions of counseling, psychology and social work (American Counseling Association [ACA], 2014; American Psychological Association [APA], 2010; National Association of Social Workers [NASW], 2008). Yet, individuals in the helping professions do not necessarily practice wellness or operate from a wellness paradigm, even though counselors are susceptible to becoming unwell because of the nature of their job (Lawson, 2007; Skovholt, 2001). As a helping professional, proximity to human suffering and trauma, difficult life experiences and additional occupational hazards (e.g., high caseloads) make careers like counseling costly for helpers (Sadler-Gerhardt & Stevenson, 2011). Further, helpers may be vulnerable to experiencing burnout because of their ability (and necessity because of their career) to care for others (Sadler-Gerhardt & Stevenson, 2011). Compassion fatigue, vicarious traumatization and other illness-enhancing issues often coincide with burnout, increasing the propensity for therapists to become unwell (Lambie, 2007; Puig et al., 2012). Extended periods of stress also can lead to helping professionals’ impairment and burnout and can negatively impact quality of client services (Lambie, 2007). Furthermore, counselors who are unwell have the potential of acting unethically and may in turn harm their clients (Lawson, 2007). Thus, it is imperative that helping professionals’ wellness be examined.
More specifically, counseling professionals are required to follow guidelines that support a wellness paradigm. ACA (2014) states that counselors should monitor themselves “for signs of impairment from their own physical, mental, or emotional problems” (Standard C.2.g.). In addition, counselors are instructed to monitor themselves and others for signs of impairment and “refrain from offering or providing professional services when such impairment is likely to harm a client or others” (ACA, 2014, F.5.b.). The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) supports counselors having a wellness orientation and a focus on prevention (Section II.5.a.) and that counselors promote wellness, optimal functioning and growth in clients (Section II.2.e.). Thus, prevention of impairment and a wellness focus are intertwined throughout the standards of the counseling profession. Consequently, it is unethical for counseling professionals to operate while personally or professionally impaired.
Wellness and Supervision in Counseling
In the following section, the importance of wellness and potential impacts of unwellness in the counseling profession will be discussed. Specifically, stressors contributing to impairment will be highlighted. In addition, supervision within a counseling context and general information regarding the supervisory experience will be reviewed.
Wellness and the Counseling Profession
The counseling profession was founded on a wellness philosophy, with holistic wellness including personal characteristics, such as nutritional wellness, physical wellness, stress management and self-care (Puig et al., 2012), and other realms including spiritual, occupational and intellectual well-being (Myers & Sweeney, 2008). According to Carl Rogers (1961), personal characteristics influence counselors’ ability to help others. For instance, individual wellness may influence how knowledgeable, self-aware and skillful supervisees are in relation to working with clients (Lambie & Blount, 2016). Counselors who are well are more likely to be helpful to their clients (Lawson & Myers, 2011; Venart, Vassos, & Pitcher-Heft, 2007), and counselors’ mental health and wellness impacts the quality of services clients receive (Roach & Young, 2007). Therefore, counselor preparation programs and supervisors should discuss wellness and areas in which impairment could arise when training students to become counselors and supervisors (Roach & Young, 2007). Though wellness is a core aspect of counselor training and preparation, many practicing counselors report their colleagues to be stressed (33.29%), distressed (12.24%) and impaired (4.05%; Lawson, 2007).
Individuals who are attracted to and enter into helping fields often appear to have severe adjustment and personality issues, and these individuals may range from students entering into programs to faculty members employed by institutions (Witmer & Young, 1996). In addition, counselors are often remiss about taking their own advice about wellness (Cummins, Massey, & Jones, 2007) and frequently preach wellness to their clients but do not practice wellness personally (Myers, Mobley, & Booth, 2003). Many counselors do not see their own impairment or are unwilling to take the steps to get help (Kottler, 2010), supporting the importance of supervisors identifying and addressing their supervisees’ impairment. Consequently, counselors seeing clients in agency settings, private practices and other settings may experience stressors that are influencing their wellness and, in parallel, the wellness of their clients.
With the counseling profession having a wellness undertone, counselors are expected to promote well-being in their clients and model appropriate wellness lifestyles. Nevertheless, counselors experience job stressors that impact their abilities to be effective helping professionals (Puig et al., 2012). Counselors face several stressors within their career such as managed care, financial limitations, high caseloads, severe mental disorders in clientele and lack of support (O’Halloran & Linton, 2000). Other factors impacting counselors and mental health professionals include: (a) compassion fatigue (Perkins & Sprang, 2012), (b) unhappy workplace relationships (Lambie, 2007), (c) vicarious trauma (Trippany, White Kress, & Wilcoxon, 2004), and (d) general fatigue (Lambie, 2007). Moreover, these systemic factors contribute to increased likelihood for counselors to experience burnout and impairment, impacting their clients’ therapeutic outcomes (Puig et al., 2012). Furthermore, counselors may not disclose their impairment because of denial, shame, professional priorities, lack of responsibility and fear of reprisal (Kottler & Hazler, 1996).
Counselor impairment occurs when counselors ignore, minimize and dismiss their personal needs for health, self-care, balance and wellness (Lawson, Venart, Hazler, & Kottler, 2007). Lawson and colleagues (2007) stated counselors need awareness of their personal wellness and should work to maintain their wellness. In addition, ACA (2014) states that counselors are responsible for seeking help if they are impaired and that it is the duty of colleagues and supervisors to recognize professional impairment and take appropriate action (Standard C.2.g.). Thus, counselors and supervisors are responsible for not only maintaining their personal wellness, but are also responsible for monitoring the wellness or impairment of their colleagues. One of the platforms for monitoring counselor wellness is supervision.
ACA (2014) stipulates that supervision involves a process of monitoring “client welfare and supervisee clinical performance and professional development” (Standard F.1.a.). Supervision is an integral component of the counseling profession, involving a relationship in which an experienced professional facilitates the development of therapeutic competence in another (Bernard & Goodyear, 2014). Furthermore, supervision is fundamental in developing and evaluating counselors’: (a) skills (Borders, 1993), (b) wellness (Lenz, Sangganjanavanich, Balkin, Oliver, & Smith, 2012), and (c) development into competent and effective counselors (Swank, Lambie, & Witta, 2012). Clinical supervisors are tasked with evaluating their supervisees’ effectiveness in addition to their level of wellness (Puig et al., 2012). Consequently, stressors, such as personal and cultural issues, addictions, burnout, and other counseling-related occupational challenges, may negatively influence supervisees’ wellness and ability to be effective helping professionals.
Supervision “provides a means to impart necessary skills; to socialize novices into particular profession’s values and ethics; to protect clients; and finally, to monitor supervisees’ readiness to be admitted to the profession” (Bernard & Goodyear, 2014, p. 5). Supervisors have the unique opportunity to operate from a wellness paradigm, socialize their supervisees to wellness practices, monitor supervisee wellness, and gauge how supervisees’ wellness influences client outcomes (Lambie & Blount, 2016). As a result, supervisors who operate from a wellness paradigm and evaluate their supervisees’ wellness may influence the wellness of supervisees’ clients by encouraging positive client outcomes (Lawson, 2007; Lenz & Smith, 2010). As such, supervisee and supervisor wellness is an important component of counselor preparation programs and clinical supervision (Lenz et al., 2012).
Counselor educators (Wester, Trepal, & Myers, 2009), clinical supervisors (Lenz & Smith, 2010; Storlie & Smith, 2012), counselors-in-training (Myers & Sweeney, 2004; Smith, Robinson, & Young, 2007), and licensed counselors (Lawson, 2007; Myers et al., 2003) face challenges in obtaining optimal well-being (e.g., high caseloads, proximity to client trauma, empathizing with students and clients). Supervisors play an integral role in counselor trainee development and can model appropriate wellness behaviors for their supervisees. Furthermore, supervisors have the unique opportunity to work closely with their supervisees and provide an in-depth look at how emerging counselors are learning about wellness behaviors, partaking in wellness actions and promoting wellness in their clients. Nevertheless, no available research has examined experienced clinical supervisors’ perceptions of their supervisees’ wellness. Because clinical supervisors have a close relationship with their supervisees, their perceptions of their supervisees’ wellness can provide important information for the counseling profession. Therefore, the following research question guided our investigation: What are clinical mental health supervisors’ experiences with their supervisees’ wellness?
Identifying themes related to clinical supervisors’ experiences of their supervisees’ wellness provides insights for both supervisors and supervisees. The researchers followed a psychological phenomenological methodology (Creswell, 2013a; Moustakas, 1994), allowing for both the meaning (themes) and the essence (experience) of the participants to be examined. In phenomenological research, researchers attempt to identify the essence of participants’ experiences surrounding a phenomenon. By developing interview questions and using an interview protocol technique (Creswell, 2013b), the researchers petitioned participants’ (i.e., clinical supervisors) direct and conscious experiences (Hays & Wood, 2011) to assess their perceptions of their supervisees’ wellness (see Table 1). The following section includes discussion on: (a) epoche and bracketing, (b) participants, (c) procedure, (d) qualitative data analysis and (e) trustworthiness.
The first course of action in phenomenological analysis is called epoche (Patton, 2015); therefore, the research team members are described with some of their potential biases. The research team consisted of two counselor educators, a counselor education doctoral candidate, and a counseling master’s student (one man and three women), all of whom identify as Caucasian. All of the researchers were affiliated with the same institution, a large, public, CACREP-accredited university located in the Southeastern United States. In addition, biases relating to the effectiveness of supervisory styles were discussed, and bracketing throughout the data analysis was implemented in order to minimize bias and allow for participant perspectives to be at the forefront. Participant experiences were documented in personal interviews and in the form of collaborative discussions.
The participants consisted of clinical supervisors who were purposefully selected from a Department of Health and Human Services counseling professional list from a large, southeastern state. Initial criteria for participation in the investigation included: (a) being clinical supervisors for 10 or more years and (b) being in an active supervisory role (i.e., providing supervision). Twenty-six participants initially responded, with 17 individuals meeting the necessary requirements for participation. The final sample consisted of six clinical supervisors, based on individuals who agreed to participate.
Criterion were established to support interviewing only “experienced” supervisors (i.e., supervisors with extensive supervision experience) and participants’ mean number of years of experience as clinical mental health supervisors was 21.2 years. Four of the experienced supervisors identified as female and two identified as male, and their ages ranged from 49 years to 63 years (M = 56.5 SD = 4.93). In addition, four of the participants identified as Caucasian (n = 4), one participant identified as Hispanic (n = 1), and one participant identified as Other (n = 1; i.e., chose not to disclose). The participants represented the following theoretical approaches: humanistic/Rogerian (n = 3), integrative/eclectic (n = 2) and cognitive-behavioral (n = 1). Primary supervision models for the clinical supervisors included: eclectic/integrative (n = 4), person-centered (n = 1) and solution focused (n = 1). The participants served as clinical supervisors at six different mental health agencies throughout a large southeastern state, supporting transferability of the findings.
In reference to wellness, the participants were asked to evaluate their level of wellness prior to participating in the interview process. Specifically, participants were asked to define what wellness meant for them as well as elaborate on the specific areas they felt influenced their wellness. Participants then rated on a 5-point Likert scale their level of overall wellness (i.e., 1 indicating very low wellness, 5 indicating very high wellness). Four of the six participants rated their overall wellness as 5 (very high wellness), while the remaining two individuals rated their overall wellness as 3 (average wellness) and 4 (high wellness) respectively. Thus, the participants reported having average to high levels of personal wellness.
Before conducting the investigation, Institutional Review Board (IRB) approval was obtained. Following IRB approval, the researchers employed purposeful sampling (Hays & Wood, 2011) to recruit participants by accessing a public listing of all mental health practitioners in a southeastern state in the United States. The Department of Health and Human Services counseling professional list was utilized, which included e-mail addresses, telephone numbers and mailing addresses of potential participants. Twenty-six participants met the initial response criteria (i.e., 10 or more years of supervisory experience). Snowballing also was used to recruit additional participants (i.e., asking participants for a name of an individual who might fit the study criteria). However, of the 26 participants, 17 supervisors responded with complete general demographic questionnaires and sufficient number of years as supervisors (i.e., minimum of 10 years). Six individuals fit the final purposive sampling criteria for participating in the investigation (e.g., had over 10 years of clinical mental health supervisory experience, still practicing as supervisors in diverse agencies, and having a complete general demographic form).
The first round of data collection was essential in confirming the eligibility of the participants (e.g., completion of the general demographic questionnaire and informed consent form). The demographic questionnaire consisted of questions about personal wellness, ethnicity, theoretical orientation, age, gender and primary population served. Following completion of the initial documents, individual interviews were scheduled. The second round of data collection involved face-to-face or Skype interviews with each participant, where participants were asked the general research question: What are your experiences with your supervisees’ wellness? The researchers also had nine supporting interview questions, which were developed through a rigorous process involving: (a) researchers’ development of an initial question blueprint derived from the literature reviewed for the study, (b) experts’ review and modification of the initial questions, and (c) an initial pilot group testing the questions. The experts were comprised of educators with experience in conducting qualitative research, experience providing supervision and familiarity with the wellness paradigm.
The interview protocol included instructions for the interviewer, research questions, probes to follow the research questions (if needed), space for recording comments, and space for reflective comments to ensure all interviews followed the same procedure (Creswell, 2013a). The general interview questions were developed to aid in addressing the overall question of supervisors’ perceptions of their supervisees’ wellness and all individual interviews were audio recorded and then transcribed. The final list of interview questions is presented in Table 1. The researchers conducted all interviews individually, and to support the effectiveness of gathering the participants’ experiences, member checking was implemented (Creswell, 2013a). Specifically, all participants were e-mailed a copy of their interview transcription, along with a statement of themes and interpretation of the interview’s meaning. All participants (N = 6) responded to member checking and stated that their transcribed interview was accurate and agreed with the themes derived from their interviews.
Interview Question Protocol
Data and Rationale
Draft Interview Questions
Prompts and Elicitations
|Values (gaining perceptions)
||1. What does wellness mean to you?
||Wellness, health, well-being
|Beliefs, Values (learning expectations, perceptions)
||2. What influences wellness in counselors?
|Values (gaining perceptions)
||3. What is the most important aspect of wellness?
|Values, (gaining perceptions, opinions)
||4. Is wellness the same or different for everyone?
||Wellness looks like . . . individualized
|Experiences, Values (what influences clients)
||5. Does wellness influence your supervisees’ client(s)?
||Wellness impacts clients, or supervisees’ clients
|Experiences, Values (gaining information on standards of wellness and if they are being upheld)
||6. Do you feel your supervisees uphold to standards of wellness in the counseling field?
||Meeting standards, CACREP, ACA Ethics
|Beliefs, Experiences (expectations of supervisors, experiences)
||7. What does unwellness in counseling supervisees look like?
||Depiction of unwellness
|Beliefs, Experiences (expectations, experiences of seasoned counselors)
||8. What does unwellness in counselors-in-the field look like?
|Values, Beliefs (gaining other information relating to wellness)
||9. Is there anything else you would like to tell me about wellness?
||Personal wellness philosophy
|Note: Draft Interview Questions were used in all participant interviews.
The researchers followed Creswell’s (2013a) suggested eight steps in conducting phenomenological research: (a) determining that the research problem could best be examined via a phenomenological approach (e.g., discussed the phenomenon of wellness and its relation to the counseling field and in the supervision of counselors); (b) identifying the phenomenon of interest (wellness); (c) bracketing personal experiences with the phenomenon; (d) collecting data from a purposeful sample; (e) asking participants interview questions that focused on gathering data relating to their personal experiences of the phenomenon; (f) analyzing data for significant statements (horizontalization; Moustakas, 1994) and developing clusters of meaning; (g) developing textural and structural descriptions from the meaning units; and (h) deriving an overall essence. In order to maintain organization, the researchers implemented color-coding of statements by selecting one color for initial significant statements or codes (e.g., step f), another color for textural descriptions (e.g., what participants experienced in step g) and a final color to represent structural descriptions (e.g., how participants experienced the phenomenon in step g) of the data (Creswell, 2013a). Finally, the researchers determined an overall essence (step h) based on the structural descriptions of the participants’ interview transcriptions. Following individual coding (i.e., steps f, g, and h), the researchers discussed their initial results and discrepancies, evaluating these discrepancies until reaching consensus.
The researchers established trustworthiness by bracketing researcher bias, implementing written epochs, triangulating data, implementing member checking, and providing a thick description of data (Creswell, 2013a; Hays & Wood, 2011). Coinciding with Denzin and Lincoln (2005), the researchers triangulated data collection using (a) a general demographic questionnaire, (b) semi-structured interviews and (c) open-ended research questions. Epochs allowed the researchers to increase their awareness on any biases present and set aside their personal beliefs. Member checking was employed in order to confirm the themes were consistent with the participants’ experiences. As such, participants were provided the opportunity to voice any concerns or discrepancies in their interview transcripts and in their derived meaning statements. The participants indicated no discrepancies or concerns. A thick description (detailed account of participants’ experiences; Lincoln & Guba, 1985) of the data was supported by the participants’ statements and derived themes. In addition, an external auditor was used to evaluate the overall themes and essence of the interviews and to mitigate researcher bias. The external auditor examined the transcripts separate from the other research members in order to evaluate the effectiveness of the derived themes and participant experiences.
Following audio recording and transcription of the participant interviews, the researchers examined the participants’ responses and generated narratives of the emergent phenomena. As a result, themes of supervisees’ wellness from the clinical mental health supervisors’ experiences were derived and included: (a) intentionality, (b) self-care, (c) humanness, (d) support and (e) wellness identity. The themes are discussed in detail below.
Intentionality was defined as the supervisor purposefully utilizing supervisory techniques and behaviors that elicit self-awareness and understanding in their supervisees (i.e., both of self and of their clients). The process of intentionality involved the supervisor actively engaging supervisees in discussions about wellness as well as actively modeling for the supervisees. Within the interviews, supervisors alluded to a parallel process that occurred between the supervisor–supervisee and supervisee–client dyads. When the supervisor intentionally modeled appropriate wellness between self and supervisee, the supervisee could then implement similar wellness activities between self and client. Reflecting on the process of supervisory modeling, Supervisor #1 stated:
The supervisor . . . has a lot . . . a lot of influence . . . checking in, what are you doing to take care of yourself? You seem really stressed, what is your wellness plan? What is your stress management? How do you detach yourself and unplug yourself from your responsibilities with your clients at work . . . to take care of you?
As depicted, the supervisor intentionally asked the supervisee questions relating to personal wellness and started a conversation about supervisees separating themselves from their work life. Supervisor #2 confirmed the importance of modeling as evidenced by the statement, “you can’t preach to someone to do something if you are not doing it yourself.” In other words, the supervisor alluded to the idea that supervisors must model appropriate professional and personal behaviors to their supervisees. Additionally, the supervisors discussed the impact of a trickledown effect (e.g., parallel process): how the supervisor approaches supervisees in turn affects how supervisees approach their clients. For instance, if the supervisor exhibited signs of burnout, then the behaviors would directly impact their relationship and understanding of the supervisee, which would indirectly impact their supervisee’s clients. Supervisor #3 noted that the wellness of supervisees influenced client wellness by saying “Oh, I can definitely see when my supervisees are unwell and how that directly influences their work with clients. It’s like they’re (supervisees) not on top of their game . . . like they’re not as effective with clients.” Furthermore, supervisors noted the use of direct interventions to help supervisees gain increased self-awareness after recognizing supervisees’ potential unwellness. Supervisor #5 stated in reference to a conversation with a supervisee, “I want you to be in the field to better help people by helping yourself and looking at your own issues.” Thus, supervisors need to be intentional when helping supervisees become more effective and more well in both their personal and professional lives.
Self-care was defined as the necessity of taking care of one’s self in order to be a better asset to supervisees and clients. The self-care theme supported the idea that “you cannot give away that which you do not possess” (Bratton, Landreth, Kellam, & Blackard, 2006, p. 15), which is consistent in the counseling and other helping professional literature (Lawson, 2007). In other words, we must take care of ourselves before we are able to care for others. Self-care is delineated from the theme of intentionality in this investigation in that supervisors reflected the importance of their own self-awareness to gauge wellness, especially to alleviate the potential for burnout. For example, Supervisor #4 stated, “If I’m not well, I can’t really help someone else get well.” Whereas the theme of intentionality reflects encouraging supervisees’ self-awareness, the self-care theme notes the importance of supervisors being self-aware and the specific actions supervisors felt they and their supervisees could take to promote self-care in their own lives. As Supervisor #6 said, “it’s an incredible field and it can be a very, very draining field if you aren’t careful, if you don’t take care of yourself.” Through the supervisors’ process of reflection and recognition, they were able to respond with care and compassion to their supervisees. However, as Supervisor #5 indicated when reflecting on counselor and supervisor burnout,
[It] happens to every single counselor, they’re going to experience compassion fatigue at some point in their career because it is a burnout job, and so to recognize . . . the signs . . . sometimes it takes someone else to point it out to us.
It is crucial to take care of oneself in counseling and be open to feedback from others who may see our behaviors from an objective standpoint. Furthermore, the supervisors noted the critical impact of taking care of themselves through activities outside of the workplace and leaving client and supervisee concerns at work. For example, Supervisor #3 noted:
I feel you need to take care of yourself, you need to do stuff for you . . . I’m clear to sit down with all of them [supervisees] and say . . .what are you going to . . . do good for yourself today . . . what are you going to do for you?
By creating differentiation between personal and professional life, supervisors and supervisees are able to rejuvenate, leading to better care for supervisees as Supervisor #1 indicated:
I do feel there are many ways to go about it . . . there’s a whole mindfulness movement, and yoga . . . animals . . . those are all ways we can go ahead and keep ourselves well. I think play is a component of keeping yourself well and . . . there are different definitions of play, but I would define it as when you’re so involved in doing something that you lose track of time. That could be art activities . . . dancing, doing something fun with your dog . . . playing games . . . being involved in something where time stands still and you’re totally in the moment. . . . I think that’s another key piece of really staying well.
As a result, the self-care theme involves supervisors identifying and implementing strategies to keep themselves well, as well as supervisees engaging in activities to support their own self-care journeys. Similar to other wellness research in the helping professions (Lawson, 2007; Myers & Sweeney, 2005b; Skovholt, 2001), self-care is paramount to supporting personal wellness, as well as having the capacity to promote wellness in others—supervisors with supervisees and in parallel, supervisees with clients.
Humanness was defined as the supervisors’ and supervisees’ culture, history, background and the influences of previous life experiences on the therapeutic relationship. Our past actions, memories and families of origin influence our worldview and current functioning. As Supervisor #3 noted, “I define wellness on a personal level, it has to do with me and my personhood, it is unique and is based on my wants and needs.” In reference to the influence of individuals’ history and background, Supervisor #2 stated, “for myself definitely it was pretty much the way I grew up . . . it depends on the population, it depends on where they were raised. . . . There’s just too many dependent variables for it.” At times, supervisors noted that these factors lead to unintentional blindness between and within the dyad (i.e., supervisor–supervisee, supervisee–client). Supervisor #3 noted that “we all have biases, we all have prejudices on some level. Are you willing to acknowledge that you are struggling with this, but I am willing to work on this, willing to go to workshops or go into therapy?” Without reflection or self-awareness, supervisors and supervisees are susceptible to similar roadblocks and “stuckness” as their clients. For instance, Supervisor #4 noted the influence of current life events impacting her overall wellness:
I think to add to that, it is the nature of our human experience. . . . we are going to go through phases in our lives where things are affected to the point to where you would say this aspect of my life is not well right now.
Thus, supervisors perceive both their humanness (e.g., backgrounds and cultures) and their supervisees’ humanness qualities as influential to the therapeutic relationship and important in supervisees’ actions in counseling situations as well as personal settings (Lambie, 2006).
Support was defined as leaning on and connecting with others (e.g., peer-to-peer, colleagues, friends, partners). Supervisors emphasized the importance of both themselves and their supervisees developing and maintaining significant relationships within the context of their job and outside the work setting. Supervisor #6 reflected that “support is integral to . . . overall wellness and, being that we are social creatures . . . support [is] really important for us.” Relationships at work can be crucial for processing tough client cases and personal issues that appear to be encroaching upon work with clients. For example, Supervisor #3 emphasized, “I think there has to be a support system of counselors who have been in the field . . . and having your own therapist.” At the same time, social relationships outside work are equally important. Similar to self-care and intentionality, separating personal life and professional life aids the supervisor and supervisee in leaving client cases at work and enjoying life beyond the role as a counselor. Within the literature, the influence of support aids supervisors and supervisees in achieving wellness and minimizing the likelihood of counselor burnout (Lambie, 2007; Lee, Cho, Kissinger, & Ogle, 2010).
Wellness identity was defined as the supervisors and supervisees operating from a wellness platform. Supervisors noted the necessity of holding this wellness platform in the forefront of conversations with students, other supervisors, and other therapists and counselors. As Supervisor #3 reflected,
We practice a strengths-based model and we see that the wellness model is depicted much, much more not only in the literature but also in the things that come about. . . . I’d rather see research in wellness rather than case research in defects.
Through attaching wellness to one’s identity as a counselor, supervisors and supervisees are compelled to continuous self-reflection on how external factors impact their work with supervisees and clients. Supervisor #1 stated “wellness is who we are, if we find ourselves straying, we probably need to re-evaluate things.” Furthermore, supervisors indicated in their interviews that wellness is an important topic for counselors and counselor educators to reflect upon and teach and discuss with students and supervisees. For instance, Supervisor #2 stated in relation to the idea of a wellness identity: “It comes from the teaching that one receives in the classroom. . . . I think that the issues have really brought it to the forefront and it has allowed us to teach wellness and to talk about it. I think teaching is the driving force.”
As shown in the wellness identity theme, all of the supervisors supported the idea that having a wellness base from which helpers operate is important. Additionally, the participants noted the importance of an open dialogue on wellness between supervisors and supervisees and, coinciding with Granello (2013) and Roach and Young (2007), stressed the idea that as a supervisor, wellness education can play a key role in promoting healthy helping professionals.
The results from this study provided the data to answer the research question: What are clinical mental health supervisors’ experiences with their supervisees’ wellness? Experienced supervisors (e.g., 10 or more years of supervisory experience) discussed areas that influenced their wellness as well as their supervisees’ wellness. Furthermore, several themes that supported an essence of supervisee wellness (Hays & Wood, 2011; Moustakas, 1994) were derived. In interviewing the supervisors, the themes of (a) intentionality, (b) self-care, (c) humanness, (d) support and (e) wellness identity were derived from the data analysis. From the results of this study, implications for clinical supervisors and counselor educators, limitations of the research investigation, and areas for future research were derived.
Implications for Clinical Supervisors and Counselor Educators
The counseling field is grounded in holistic wellness (Myers & Sweeney, 2004). Therefore, our findings reflected the theme that wellness is important to the counseling profession and in supporting supervisors’ and supervisees’ overall growth. Scholars in the helping fields (Keyes, 2002, 2007; Myers, Sweeney, & Witmer, 2000) and professional guidelines (ACA, 2014; CACREP, 2015) support the necessity of a wellness focus, identifying that a lack of a wellness focus may lead to unwellness and burnout (Bakker, Demerouti, Taris, Schaufeli, & Schreurs, 2003). Thus, creating and maintaining a wellness identity in supervision can aid in supporting holistic wellness in supervisees. In addition, self-care can be important for counselors, as they are not immune to difficult experiences and life events faced by their clients (Venart et al., 2007). Supervisor #6 noted that burnout was an inevitable part of working as a counselor and, similarly, researchers have identified that burnout can influence counselors’ work with their clients (Lambie, 2007; Puig et al., 2012). Thus, wellness provides the foundation of helping professionals’ work with clients (Venart et al., 2007), and exploration of counselor burnout and other negative consequences of counselor unwellness warrants attention.
The clinical supervisors in our investigation indicated a need for counselor educators to be more intentional in their focus and inclusion of wellness with the therapeutic relationship. In order to mitigate the effects of burnout and unwellness in supervisees, a wellness course or a wellness plan for counselors-in-training over the duration of their preparation program is suggested to support counselor educators in preparing future clinicians with a mindset of reflection, process and activities to enhance wellness. By implementing a wellness focus throughout preparation programs, supervisees can learn about the positive and negative influence of their wellness choices, as well as the effects their wellness may have on their colleagues and clients. Furthermore, wellness plans could be implemented throughout the program to promote wellness awareness in supervisees. Classroom discussions and wellness groups could also aid in supporting students in their wellness growth and development throughout their program while providing counselors-in-training with the tools to share their knowledge and promote wellness in others.
Supervisors also can mitigate the effects of unwellness by continuously evaluating their current levels of functioning through formal assessments such as the Five Factor Wellness Inventory (5F-Wel; Myers & Sweeney, 2005a), or the Helping Professional Wellness Discrepancy Questionnaire (HWPDS; Blount & Lambie, in press) or informal assessments such as wellness journaling or implementing wellness plans. Supervisors also may choose to include wellness in their supervision sessions by assessing pre- and post-wellness levels in supervisees, operating from a wellness-supervision paradigm (e.g., the Integrative Wellness Model; Blount & Mullen, 2015; Wellness Model of Supervision; Lenz & Smith, 2010), having educational discussions on the holistic components of wellness, and modeling appropriate wellness behaviors. Thus, there are numerous actions supervisors can take to promote individual wellness, include wellness in their supervision, and promote wellness in their supervisees.
Supervision is crucial to counselor development (Bernard & Goodyear, 2014). CACREP (2015) Standards and licensure requirements emphasize the importance of supervision throughout trainees’ growth and establishment as a professional counselor. ACA (2014) emphasizes additional professional development and supervision throughout counselors’ careers, stating that counselors should “regularly pursue continuing education activities including both counseling and supervision topics and skills” (Standard F.2.a.). Even though the field of counseling is grounded in a wellness paradigm (ACA, 2014; CACREP, 2015), the process of supervision does not always support a wellness focus, as supervisors do not model wellness for their supervisees or stress the importance of counselor well-being. According to the supervisors in our investigation, wellness should be integrated and discussed within the supervision realm. Further, clients are more likely to benefit from a well counselor (Lawson, 2007) and as such, counselor educators and supervisors face the challenge of promoting effective, well therapists-in-training. The wellness process, however, typically occurs in a negative trickledown method (e.g., burned out supervisors modeling inappropriate wellness behavior for trainees who in return model inappropriate wellness for clients).
Counselor educators can break the cycle of negatively modeling wellness by incorporating wellness throughout the trainees’ experience in their preparation programs and by modeling wellness and self-care. Through the wellness paradigm, counselor educators can begin to change the thought process of trainees’ own reluctance to engage in self-care and work to change the “do as I say” mentality (i.e., telling clients or trainees to be well when we are not well ourselves), which is present throughout the helping professions (Lawson, 2007; Witmer & Young, 1996). Based on our results, the counseling profession should embrace the belief that “you cannot give away that which you do not possess” (Bratton et al., 2006; p. 238). By adapting a wellness framework, the benefits of the wellness paradigm at the beginning of trainees’ careers is significant, impacting other counselors and clients that enter into their path in a positive way.
Expanding beyond supervisors, therapists-in-training and practitioners, wellness practices can be influential on a larger scale. Counseling and counselor education programs, as well as respective professional organizations, can use wellness philosophies and practices to promote self-care in their members. In addition, organizations can support strong wellness identities in their helping professionals by upholding their ethical standards, promoting wellness-related actions, and educating new professionals on the importance of practicing wellness in their personal and professional lives. As voiced by many of the supervisors interviewed in our study, professional organizations can support their members by encouraging wellness identities and offering platforms for individuals to form relationships with other practitioners in the field. Practitioners can use the connections to exchange wellness ideas and practices, and offer support as professionals. Finally, supervisors can be integral in promoting their supervisees’ wellness throughout the career, supporting the services they provide to diverse clients.
We followed steps to support the trustworthiness of the data; however, some limitations are noted. Given that the first author is invested in the wellness approach to counseling, researcher bias may have occurred. However, the research team implemented steps to mitigate the role of bias. For instance, researcher bias was bracketed at the forefront of the interviews and an external auditor reviewed interviews to note themes separate from the research team. As with all qualitative research, the results from our study are not generalizable. Nevertheless, the six clinical mental health supervisors worked in six different mental health agencies, supporting the transferability of the findings (Yardley, 2008). In addition, the sample size for the investigation met the criteria outlined for qualitative analyses (5–25 participants; Polkinghorne, 1989), yet all of the participants volunteered for participation and may have had a greater interest in wellness than those who did not volunteer. Finally, even with a small sample size (N = 6), the researchers believed that saturation of the themes occurred by implementing rigorous data analytic procedures (i.e., coding for themes and essence) and reaching an inability to glean new information from the coding (Guest, Bunce, & Johnson, 2006).
Areas for Future Research
In relation to future research endeavors, participants in this study emphasized the importance of wellness-related research in counseling. Given that the counseling field is grounded in a wellness model (Myers & Sweeney, 2005b; Witmer, 1985) and that limited studies on wellness are available, quantitative and/or qualitative studies examining the overall effect of wellness within the supervisory relationship are needed. Further, researchers might assess the degree to which supervisors or supervisees actually engage in wellness behaviors. As with most qualitative studies, our findings reflect a starting point for quantitative research, focusing on the identified themes across supervisors and supervisees. Future researchers could examine the parallel process between (a) educator and student and (b) supervisor and supervisee that takes place when trusting and safe relationships are established (Bernard & Goodyear, 2014). Furthermore, future researchers could assess differences in supervisors or supervision styles in supervisors with formal supervision courses versus no formal experience; or similar studies with supervisors who have participated in a wellness course versus those who have not. In addition, future research could focus on client outcomes when one party (i.e., counselor) models appropriate wellness and a different counselor does not model these qualities. Future researchers are also encouraged to assess the effect of the five identified themes on client outcomes and/or student progress within counselor education programs.
In summary, “it is not possible to give to others what you do not possess” (Corey, 2000, p. 29); therefore, we must take care of ourselves before we are fully capable to help others. As such, it is important to bring wellness to the forefront of clinical supervision and remain engaged in promoting personal wellness and the wellness of others. Thus, assessing and evaluating wellness in all supervisors and supervisees (counselors) is integral in providing quality supervision and efficacious counseling services and protecting client welfare. By increasing awareness on wellness themes, such as self-care, support, wellness identity, and humanness, along with operating intentionality, clinical supervisors can support their supervisees in achieving greater levels of wellness.
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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Ashley J. Blount, NCC, is an Assistant Professor at the University of Nebraska Omaha. Dalena Dillman Taylor is an Assistant Professor at the University of Central Florida. Glenn W. Lambie, NCC, is a Professor at the University of Central Florida. Arami Nika Anwell is a recent graduate of the University of Central Florida. Correspondence can be addressed to Ashley Blount, 6001 Dodge Street, RH 101E, Omaha, NE 68182, firstname.lastname@example.org.