Self-care And Well-being in Mental Health Professionals

7/24/2019 Self-care And Well-being in Mental Health Professionals

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Self-care and well-being in mental

health professionals: the mediating

effects of self-awareness and

mindfulness.

Richards, Kelly C.

Campenni, C. Estelle

Muse-Burke, Janet L

Journal of Mental Health

Counseling Publisher: American Mental

Health Counselors, July, 2010 Source

Volume: 32 Source Issue: 3

Because mental healthprofessionals are susceptible to

impairment and burnout that may

negatively affect clinical work, it is

ethically imperative that they

engage in self-care.

Previous research has found direct

effects of self-care on self-

awareness and well-being (e.g.,

Coster & Schwebel, 1997).

Likewise, mindfulness has been

found to positively affect well-being

(Brown & Ryan, 2003). However, no

studies currently available

demonstrate a link between self-

awareness and well-being.

Mindfulness may be the link needed

to support this association. A survey

of mental health professionals (N =

148) revealed that mindfulness is a

significant mediator between self-

care and well-being. Consequently,

mental health professionals are

encouraged to explore their

involvement in and beliefs about

self-care practices.

**********

According to the core ethical

principles of counseling, counselors

have a responsibility to do no harm,

benefit others, and pursue

excellence in their profession

(American Counseling

Association [ACA], 2005; American

Mental Health Counselors

Association, 2010). Mental health

professionals are susceptible to

impairment in their professional

lives that can undermine their

therapeutic efficacy (Coster &

Schwebel, 1997). Coster and

Schwebel find that mental health

professionals are vulnerable to,

e.g., vicarious trauma, substance

abuse, relational difficulties, and

depression. Therefore, to adhere to

their ethical principles, it is

important that counselors engage in

self-care (e.g., exercise) to

decrease the possibility of

impairment and enhance their well-

being.

The present study explored the link

between self-care by mental health

professionals and their general well-

being. Previous research has found

direct effects of self-care on well-

being (e.g., Coster & Schwebel,

1997) and self-awareness (e.g.,

Mackey & Mackey, 1994); however,

no studies demonstrate a linkbetween self-awareness and well-

being. This omission is interesting

considering that mindfulness, which

has been associated with self-

awareness, has been shown to

have a direct effect on well-being


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(e.g., Brown & Ryan, 2003). This

study therefore examined the direct

effect of self-care on self-awareness

and mindfulness and how these

associations affect the well-being of

mental health professionals.

What Is Self-care?

The literature reveals few attempts

at an operational definition of self-

care, and there is minimal

agreement among definitions. For

example, Pincus (2006) defined

self-care vaguely as something

"one does to improve [the] sense of

subjective well-being. How one

obtains positive rather than negative

life outcomes" (p. 1). Other

researchers have defined self-care

by describing activities believed to

constitute self-care. Carrol, Gilroy,

and Murra (1999) classify self-care

as including "intrapersonal work,

interpersonal support, professional

development and support, andphysical/recreational activities" (p.

135). With these definitions in mind

and after a thorough literature

review, some general themes in

self-care have been identified.

Researchers have explored

physical (Mahoney, 1997),

psychological (Norcross, 2000),

spiritual (Valente & Marotta, 2005),

and support (Guy, 2000)components of self-care.

Physical. The physical component

of self-care has been loosely

defined as incorporating physical

activity (Carroll et al., 1999), which

in this context is characterized by

bodily movement that results in the

utilization of energy, which can

occur through exercise, sports,

household activities, and other daily

functioning (Henderson &

Ainsworth, 2001). The intensity of

physical activity and the amount of

time spent on it can vary

dramatically, but recommendations

from the U.S. Department of

Healthand Human Services and the

U.S. Department of Agriculture

(2005) suggest at least 30 minutes

of physical activity for most days

throughout the week is necessary to

receive benefits

Although there seem to be many

specific advantages of physical

activity (Dishman, 2003), it also

appears to have a general wellness

benefit. It has been shown to

decrease symptoms of anxiety and

depression (Callaghan, 2004;

Dishman). Further, Lustyk, Widman,Paschane, and Olson (2004) found

that an increase in the volume and

frequency of exercise increased the

health component of quality of life.

For instance, physical activity has

been shown to increase women's

satisfaction with their body

functioning and their ability to cope

with daily stress (Anderson, King,

Stewart, Camacho, & Rejeski,2005). Clearly, physical activity

promotes a general sense of well-

being.

Psychological. Psychological self-

care refers to seeking one's own


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personal counseling (Coster &

Schwebel, 1997; O'Connor, 2001).

Personal counseling can be defined

as psychological treatment for any

type of distress or impairment

(Norcross, 2005). Patterson (1966)

states that counseling is a process

"involving a special kind of

relationship between a person who

asks for help with a psychological

problem ... and a person who is

trained to provide that help" (p. 1).

Because counselors spend a

significant amount of time providing

services to others, it is suggested

that they themselves seek the

benefits of counseling.

Among the benefits found through

participation in personal counseling

is alleviation of symptoms of

distress and impairment (Macran,

Stiles, & Smith, 1999). Through

qualitative interviews with

therapists, researchers have also

identified other personal andprofessional benefits (Mackey &

Mackey, 1994; Macran et al.).

Personal counseling supports

personal development by allowing

one both to understand how to care

for oneself and to develop an

awareness of one's boundaries and

limitations (Mackey & Mackey;

Macran et al.,). Professional

development, which is understoodas building awareness of skills that

can benefit one'scareer, has also

been demonstrated to be a result of

personal counseling. Because

empathy requires understanding of

another person, personal

counseling has been shown to

enhance counselors' empathic skills

(Mackey & Mackey; Macran et al.).

Given the personal and professional

development that results, it appears

that becoming aware of oneself is a

significant advantage of personal

counseling (Coster & Schwebel,

1997; Mackey & Mackey; Macran et

al.; Norcross, 2005).

Spiritual The spiritual component

of self-care also must be defined

loosely, given how broadly its

meaning can be interpreted.

Spirituality can be generallydescribed as a sense of the

purpose and meaning of life and

the connection one makes with

this understanding (Estanek, 2006;

Hage, 2006; Perrone, Webb,

Wright, Jackson, & Ksiazak, 2006;

Saucier & Skrzypinksa, 2006). This

definition is vague enough to

ensure that all beliefs of spirituality,

including religion, are addressed.Behaviors sometimes considered

spiritual, such as meditation, may

also be included (Schure,

Christopher, & Christopher, 2008).

Boero et al. (2005) investigated

the spiritual/religious beliefs and

quality of life of health workers.

They found that spirituality plays a

significant, positive role in theirquality of life. Physical well-being,

such as health, was also found to

be significantly, positively

influenced by spirituality (Boero et

al.).


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Mental health has been shown to

be related to spirituality (Wong,

Rew, & Slaikeu, 2006). It was

found that greater spirituality

reported by adolescents was

associated with more positive

mental health (Wong et al.). In

another study using qualitative

interviews, helping professionals

discussed their spirituality and its

benefits to them. It was reported to

promote not only quality of life but

also a sense of self-awareness

(Hamilton & Jackson, 1998).

Hamilton and Jackson suggest

that self-awareness is central to

developing and maintaining

spirituality; therefore, it might be

supposed that spirituality is

important for the development and

continued progression of self-

awareness.

Support. The support component

of self-care includes the

relationships and interactions thatdevelop from both professional

and personal support systems.

Professional support is defined as

consultation and supervision from

peers, colleagues, and supervisors

and the continuation of

professional education (Coster &

Schwebel, 1997; O'Connor, 2001;

Stevanovic & Rupert, 2004).

Personal support is defined asrelationships with spouse,

companion, friends, and other

family members (Coster &

Schwebel; Stevanovic & Rupert).

Like personal therapy, support

from others can benefit personal

and professional development.

Koocher and Keith-Spiegel (1998)

suggest that mental health

professionals should participate in

routine professional

communications with colleagues to

reduce the possibility of burnout.

Through consultation and

supervision, it is possible to

recognize and understand

oversights and errors (Koocher &

Keith-Speigel; O'Connor, 2001).

Also, professional support can

help guide a counselor through

ethical and other clinical difficulties

with cases (Coster & Schwebel,

1997). Mental health professionals

surveyed indicated that

professional support was the main

reason for their well-being

because it gave them input into

various situations (Coster &

Schwebel). Because professional

development can occur through

professional support as well aspersonal counseling, self-

awareness may also develop from

such support systems.

Stevanovic and Rupert (2004)

surveyed licensed psychologists

about their career satisfactions

and found that it is important not to

use personal support for

professional stressors becausepersonal support provides different

benefits. Specifically, it satisfies

the common need to belong

because it establishes

relationships outside the

professional world. It therefore


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provides a healthy balance in that

mental health professionals will

experience their lives through both

career and outside of work (Coster

& Schwebel, 1997; Stevanovic &

Rupert). This balance can help

prevent or alleviate symptoms of

burnout and mental exhaustion, or

becoming a workaholic. It has

been suggested that personal

support enhances psychological

well-being (life satisfaction and

mood) and physical health

subjectively and objectively (Walen

& Lachman, 2000).

What Is Self-awareness?

A comprehensive literature review

reveals minimal discussion of the

construct of self-awareness,

making defining it difficult.

Additionally, most of the research

that has examined self-awareness

is outdated. Brown and Ryan

(2003) suggest that it is simply"knowledge about the self" (p.

823). Others suggest that self-

awareness is awareness or

knowledge of one's thoughts,

emotions, and behaviors and can

be considered a state; therefore, it

can be situational (Fenigstein,

Scheier, & Buss, 1975). It is

believed to be similar to or

synonymous with other constructs,such as self-consciousness

(Fenigstein et al.; Webb, Marsh,

Schneiderman, & Davis, 1989) and

insight (Grant, Franklin, &

Langford, 2002; Roback, 1974).

Because this study is exploring

self-care and its benefits, which

have been shown at times to be

self-awareness, it is important to

emphasize distinguishing self-

awareness as a state. The

outcome of a behavior usually

tends to be a state; therefore, self-

awareness may be a possible

outcome of self-care.

What Is Mindfulness?

Once again, definition is a

daunting task. Mindfulness has

only recently been introduced to

Westernized culture and there is

still uncertainty about its exact

definition. Researchers have a

consensus understanding that it is

maintaining awareness of and

attention on one's surroundings;

however, several models have

been proposed for a more precise

definition (see Bishop et al., 2004;

Shapiro, Carlson, Astin, &

Freedman, 2006; Sternberg,2000). It has been suggested that

the practice of mindfulness may

facilitate insight, which can be

understood as awareness of

oneself and one's motives

(Rosenzweig, Reibel, Greeson, &

Brainard, 2003; Schmidt, 2004).

Because insight and self-

awareness have been described

similarly, any connection betweenself-awareness and mindfulness

should be explored.

Despite the suggested similarities

between self-awareness and

mindfulness, some researchers


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have begun to identify subtle

differences. Brown and Ryan

(2003) believe self-awareness to

be "knowledge about the self" (p.

823), whereas mindfulness can be

understood as knowledge and

awareness of one's experience in

the present moment (Byrne, 2007;

Hirst, 2003). More specifically,

Brown and Ryan propose that self-

awareness is an internal

awareness of one's cognitions and

emotions, and mindfulness is both

internal and external, being

awareness of both one's

cognitions and emotions and the

surrounding environment.

Mindfulness has been used as an

intervention for physical ailments in

the form of structured mindfulness

meditation instruction, known as

mindfulness-based stress

reduction (MBSR; Bishop, 2002).

Through this meditation, the

patient begins to develop anunderstanding of the self and

ultimately an ability to regulate the

self (Bishop). The technique

teaches people to notice, accept,

and regulate their emotions and

thoughts (Bishop). MBSR has

been used successfully to reduce

stress (Rosenzweig et al., 2003)

and relieve medical illness

(Bishop; Kabat-Zinn et al., 1998),psychological distress (Williams,

Teasdale, Segal, & Soulsby,

2000), and physical and emotional

pain (Roth, 1997).

Purpose and Hypotheses

Research has thus established

that mindfulness has a strong link

with self-awareness and well-being

(Brown & Ryan, 2003), and that

self-care has a direct effect on self-

awareness (Hamilton & Jackson,

1998) and well-being (Lustyk et al.,

2004). However, it has not clearly

delineated the direct link between

self-awareness and well-being.

Although it appears that self-care

leads to well-being (Coster &

Schwebel, 1997), it has yet to be

determined if self-awareness

mediates the relationship between

self-care and well-being. If

mindfulness and self-awareness

are associated, and mindfulness

leads to well-being, it would seem

logical that there would be a chain

linking self-care to self-awareness

to well-being. This study explored

such links by examining self-care

practices, self-awareness,

mindfulness, and well-being inmental health professionals.

The following hypotheses were

examined:

Hypothesis 1: A significant,

positive correlation between self-

awareness and mindfulness will be

found.

Hypothesis 2: The path from self-

care to mindfulness to well-being

will be significantly stronger than

the direct path from self-care to

well-being.


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Hypothesis 3: The path from self-

care to self-awareness to well-

being will be significantly stronger

than the direct path from self-care

to well-being.

METHOD

Participants

The study surveyed 148 mental

health professionals holding a

bachelor's degree or higher and

practicing in the northeastern

United States. According to Cohen

(1992), based on the number of

variables used a minimum of 108

participants is required to achieve

power of .80 with an alpha of .01

and a medium effect size (r = .30).

The participants were 77.1%

women; the average age was

42.38 years (SD = 14.88); and

94.3% were White, 2.1% Asian

American, 2.1% Latino/Latina,

0.7% African American, and 0.7%Native American. In terms of

educational level, the participants

were somewhat evenly distributed

(30.6% bachelor's, 41.7%

master's, 0.7% educational

specialist/ABD, 26.4% doctorate,

and 0.7% other). Their specialties

were in social work (43.3%),

counseling psychology (24.8%),

clinical psychology (23.4%), other(7.1%), and general psychology

(1.4%). Participants reported that

they currently provide mental

health services, defined as seeing

clients for assessment, therapy,

and psychological testing in a

variety of settings; some

respondents worked in multiple

settings, including community

mental health center (15.5%),

inpatient hospital (5.4%), partial

hospitalization program (8.1%),

practicum/internship (12.8%),

private practice (40.5%), Veterans

Affairs clinic (0.7%), nonprofit

organization (2.0%), children's

welfare center (4.7%), university

counseling center (9.5%), and

other mental health setting (8.8%).

Average years in practice was 13.8

years (range = 0 - 40).

Measures

Self-care. Participants were given

a broad definition of self-care

("Self-care refers to any activity

that one does to feel good about

oneself. It can be categorized into

four groups which include:

physical, psychological, spiritual,

and support") and definitions forthe four components. They were

asked to indicate how often they

are involved in such behaviors

based on a 7-point Likert-type

scale ranging from "One or more

times daily" (0) to "Never" (6).

There were four questions, one for

each aspect of self-care. For

example, one item asked

participants to identify how oftenthey engaged in physical activities

(exercise, sports, household

activities, etc.). Since each

question was developed to assess

a component of self-care that is

independent of the others, inter-


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item reliability could not be

assessed. Items were reverse-

scored to produce final scores of

zero to 24. Higher scores indicate

greater propensity for self-care.

Participants were also asked to

indicate their views of the

importance of each self-care

component. They were again

provided with a broad definition of

self-care and the definitions of its

four components. They were

asked to indicate the extent to

which they agreed with each of

four statements pertaining to the

importance of self-care activities,

ranging from "Disagree Strongly"

(0) to "Agree Strongly" (6). The

possible final range of scores was

zero to 24, with higher scores

indicating greater agreement with

the importance of self-care. Again,

reliability could not be assessed

for this measure.

Self-awareness. The Self-

Reflection and Insight Scale

(SRIS; Grant et al., 2002) has two

subscales, self-reflection and

insight. Grant and colleagues

defined self-reflection (p. 821) as

"the inspection and evaluation of

one's thoughts, feelings, and

behavior" and insight as "the clarity

of understanding one's thoughts,feelings, and behavior." The self-

reflection subscale can be further

divided into the need for self-

reflection and engagement in self-

reflection, which have been shown

to be subcomponents but are not

separated out from the main self-

reflection subscale (Grant et al.).

The SRIS consists of 20 self-report

items, to be rated on a 6-point

Likert-type scale ranging from (1)

"Strongly Disagree" to (6) "Agree

Strongly." Eight of the items are to

be reverse-scored. Possible

scores range from 20 to 120, with

higher scores indicating more self-

awareness. Grant et al. report that

SILLS has high internal

consistency, with Cronbach's

alphas of .91 (self-reflection

subscale) and .87 (insight

subscale). The SRIS has also

been shown to have good seven-

week test-retest reliability with

alphas of .77 (self-reflection

subscale) and .78 (insight

subscale). Grant et al. found the

SRIS to demonstrate good

convergent and discriminant

validity in that both subscales were

not related to depression; the

insight subscale was notcorrelated with anxiety,

alexithymia, or stress; and the

insight subscale was positively

related to self-regulation and

cognitive flexibility. Cronbach's

alphas for the current sample were

.78 (self-reflection) and .94

(insight).

Mindfulness. The Mindful AttentionAwareness Scale (MAAS; Brown &

Ryan, 2003) was utilized in the

present study to assess

individuals' levels of mindfulness.

The MAAS is a 15-item self-report

measure scored on a 6-point


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Likert-type scale, ranging from (1)

"Almost Always" to (6) "Almost

Never." Possible scores range

from one to six, with higher scores

indicating greater propensity to be

mindful. Reliability was good, with

alphas ranging from .82 to .87.

During a test-retest analysis

(Brown & Ryan), the measure did

not produce significantly different

scores between Time 1 and Time

2, again indicating reliability.

Based on two different

confirmatory factor analyses

utilizing student and general adult

samples, the MAAS was found to

measure a single factor. Good

convergent validity has been

demonstrated in that this measure

was found to correlate with

emotional intelligence, openness

to experience, and wellbeing

(Brown & Ryan). Discriminant

validity was shown by a low

correlation between the MAAS and

self-examination, self-monitoring,and neuroticism (Brown & Ryan).

Cronbach's alpha for the current

sample was .89.

Well-being. This study used the

Schwartz Outcomes Scale-10

(SOS-10; Blais et al., 1999) to

evaluate participants' well-being. It

consists of 10 self-report items

assessing psychological healththat are rated on a 7-point Likert-

type scale ranging from (0) "Never"

to (6) "All of the time or nearly all

of the time." Possible scores range

from zero to 60, with higher scores

indicating greater psychological

health. Blais and colleagues report

that the SOS-10 has high internal

consistency, with Cronbach's

alpha >.90 over three samples. It

has also been shown to have good

test-retest reliability (r = .87)

across a one-week study with a

nonpatient population (Blais et al.).

Further, there were no floor or

ceiling effects found among patient

or nonpatient populations. The

SOS-10 was found to have high

convergent validity in that it had a

significant positive correlation with

positive affect, sense of

coherence, self-esteem, and

general life satisfaction (Blais et

al.). It also was found to have high

discriminate validity, as

demonstrated by its significant

negative correlation with negative

affect, hopelessness, fatigue, and

psychiatric symptoms (Blais et al.).

Cronbach's alpha for the current

sample was .88.

Demographics. The questionnaire

asked about age, gender,

race/ethnicity, educational degree,

field of study, and professional

practices.

Procedure

Two methods were used to mail

415 survey packets, including aself-addressed, postage-paid

envelope. First, those identified as

mental health professionals under

the "Counseling Services" and

"Psychologists" sections of the

phonebook in northeastern


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Pennsylvania were contacted.

Second, counseling and clinical

psychology graduate students who

were actively providing mental

health services were solicited

through personal contact with

training directors. Reminder

postcards were mailed one week

after the surveys. Completion of

the survey packet constituted

agreement to participate. The

return rate was 35.7%--148

surveys. The order of the

questionnaires was

counterbalanced to decrease

potential response bias; but the

questionnaire on self-care

importance was always last so

those responses would not

influence responses to the other

measures.

RESULTS

Before analysis the data were

screened using Mahalanobisdistance to assess for outliers.

This analysis identified three

multivariate outliers, which were

removed from the data.

Descriptive Statistics

The descriptive statistics for each

measure are found in Table 1.

Bivariate correlations wereconducted on all measures (see

Table 1). Self-care frequency is

significantly, positively correlated

with self-care importance (r = 0.34,

p < .001) and well-being (r =

0.228, p = .008). Self-awareness

was also positively correlated with

self-care importance (r = 0.325, p

< .001), well-being (r = 0.174, p =

.045), and mindfulness (r = 0.293,

p < .001). The connection between

self-awareness and mindfulness

supports the hypothesis that these

two constructs would be

significantly correlated.

Additionally, mindfulness (r =

0.179, p = .035) and well-being (r

= 0.208, p = .014) were found to

be positively correlated with self-

care importance, though the

associations were weaker. Lastly,

mindfulness was found to be

positively, strongly correlated with

well-being (r = 0.541, p < .001).

Mediational Analysis

According to Baron and Kenny

(1986), a mediational analysis is

used to assess the indirect effects

of one variable between an

independent and an outcomevariable. This model demonstrates

that a relationship may exist

between an independent and an

outcome variable, while an

additional variable (a mediator)

may be significantly correlated with

both. This mediator variable may

account for a significant portion of

the correlation between the

independent and the outcomevariables. The mediator, which

explains the "how or why" of a

relationship, may be described as

an "internal psychological" variable

that accounts for the relationship

between two "external physical"


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constructs or experiences (Baron

& Kenny, p. 1176). An evaluation

of the indirect effects that exist

between the direct effects of the

independent and outcome

variables may weaken or eliminate

these direct effects.

Multiple conditions must be met to

conduct the mediational analysis

proposed by Baron and Kenny

(1986). A series of simple and

multiple regressions is conducted

to determine if these are satisfied.

The first condition that must be

met is the presence of a significant

relationship between the

independent and the outcome

variable. There also needs to be a

significant relationship between

the independent and the mediating

variable. Next, it is essential that

there be a significant relationship

between the mediator and the

outcome variable. Lastly, the

significant relationship betweenthe independent and the outcome

variable must diminish when the

effects of a mediating variable are

held constant. Baron and Kenny

reasoned that a "perfect

mediation" is present when there is

no longer a relationship between

the independent and the outcome

variable when the mediating

variable is held constant (p. 1177).

Self-care Importance, Mindfulness,

and Well-being. A mediational

analysis was conducted to assess

the indirect effects of self-care on

well-being. In the first step, it was

found that self-care importance

was significantly, positively

correlated with well-being (r =

.208, p = .014). In the second, it

was found that mindfulness was

significantly, positively correlated

with self-care importance (r =. 179,

p = .035). In the third, mindfulness

significantly affected well-being

when self-care importance was

controlled for ([R.sup.2] = .292,

F[1,137] = 56.594, p < .001, Beta =

.520, p


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Self-care Frequency, Mindfulness,

and Well-being. To assess

whether mindfulness is a

significant mediator of the

relationship between self-care and

wellbeing in mental health

professionals, first self-care

frequency was explored. In the

initial step of the mediational

analysis, self-care frequency and

well-being were significantly,

positively correlated (r = .228, p =

.014), but self-care frequency and

mindfulness were not (r =. 151, p =

.079), indicating that mindfulness

is not a significant mediator

between self-care frequency and

well-being. Thus the hypothesis

that self-care and well-being are

directly mediated by mindfulness is

not supported.

Self-care Importance, Self-

awareness, and Well-being. In the

first step of the analysis of whether

self-awareness mediated therelationship between self-care

importance and well-being, it was

found that self-care importance

was significantly, positively

correlated with well-being (r =

.208, p = .014). In the second step,

self-awareness and self-care

importance were significantly,

positively correlated (r = .325, p

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Self-care And Well-being in Mental Health Professionals