Mindfulness and the Integration of Self-Care in Clinical Training
Building mindfulness training into clinical practice instruction can serve several simultaneous goals. Perhaps the most modest of these goals is to have clinical training keep pace with advances in the field as mindfulness-based approaches are increasingly finding empirical support and are rapidly being incorporated into clinical treatments for a wide variety of disorders (Baer, 2003; Didonna, 2009). A broader benefit to students lies in the promise of mindfulness training to provide a means of fostering foundational qualities and skills, such as attention, empathy, warmth, equanimity, openness, and affect tolerance, which have remained in large measure beyond the reach of training. Finally, mindfulness practices do themselves represent a form of self-care that has been shown to reduce anxiety and distress as well as increase well-being among clinical practitioners. Mindfulness training may therefore provide an avenue to prevent and address vicarious trauma and burnout, further increasing the social worker’s well-being and effectiveness. There have been few enough developments in the history of the field that have provided a means of improving psychotherapy outcome, a method of developing clinical skills, and a means of supporting the health and well-being of the clinician simultaneously. As a method of clinical instruction, mindfulness training holds great promise for clinical educators, their students, and their clients alike.
Professionals who care for others are vulnerable to occupational stress as the result of their care-giving role. For example, practicing psychotherapists consistently report significant levels of emotional exhaustion, anxiety, and depression (Norcross, 2000; Radeke & Mahoney, 2000). One recent study of psychologists demonstrated that 4 in 10 were experiencing clinically significant levels of distress (May & O’Donovan, 2007). Occupational stress can have a very significant impact on a clinician’s health and well-being, interpersonal relationships, occupational functioning, and even longevity in the profession (Lloyd, King, & Chenoweth, 2002).
Clinical social workers may be particularly vulnerable to occupational stress because they often work at agencies with fewer supports, perform ambiguous or conflicting roles, experience large caseloads, and work with clients with the fewest resources (Coyle, Edwards, Hannigan, Fothergill, & Burnard, 2005; Lloyd et al., 2002). Although self-care is regarded as the sine qua non of managing occupational stress on an individual level (Figley, 2002; Norcross, 2000), few, if any, clinical training programs integrate self-care into the curriculum (Newsome et al., 2006). Vicarious trauma and burnout are two common manifestations of occupational stress. Let’s explore how mindfulness training may prevent and reduce these and other manifestations of occupational stress.
Compassion fatigue, secondary traumatic stress, and vicarious trauma are interchangeable terms for a recently acknowledged psychological syndrome among clinicians who are exposed to trauma through treating traumatized clients (Collins & Long, 2003; Figley, 2002). The syndrome replicates the effects of posttraumatic stress disorder as clinicians who have compassion fatigue, like their clients, experience increased arousal, numbing, reexperiencing, and the avoidance of traumatic stimuli, which can significantly impair their well-being (Collins & Long, 2003; Hesse, 2002). Novice clinicians are particularly vulnerable to the effects of traumatic exposure in the classroom as well as at the practicum site (Hesse, 2002; Jones, 2002). Because empathic engagement is viewed as a prerequisite to compassion fatigue (Figley, 2002), it may be that the very students who are most effective may also be most vulnerable to secondary traumatic stress. Students who have their own unresolved traumatic experiences may also be more vulnerable to being restimulated by exposure to clients with similar experiences (Collins & Long, 2003; Figley, 2002).
Few schools adequately prepare their students to identify, normalize, and respond to vicarious trauma. Hesse (2002) described the intense fear, hypervigilance, pain, and avoidance she experienced after interviewing a batterer and his victim in her practicum placement as a social work student. Figley (2002) provided another example of a counseling trainee who was referred to therapy by her supervisor because vicarious trauma was interfering with her ability to respond to her client’s needs. The symptoms of secondary traumatic stress can significantly affect a therapist’s effectiveness (Figley). After all, it’s difficult to help your client process a traumatic experience if you want to avoid discussing it. Hesse (2002) talked about how little initial information she had to make sense of her reactions to her clients. The professional silence that too often accompanies vicarious trauma keeps clinicians isolated (Figley). Novice clinicians, in particular, may be likely to read their symptoms as a failure in coping on their part. Add vicarious trauma to the baseline anxiety of applying nascent clinical skills in a first or second practicum and you may be much more likely to have students who are overwhelmed and at risk of failure.
Mindfulness training, combined with information about vicarious trauma, may function as a possible preventative to secondary traumatic stress. Because mindfulness training increases one’s awareness of the physical, emotional, and mental dimensions of being, and provides a means of processing experience, the student who is practicing mindfulness is more likely to become aware of and process the impact of secondary traumatic exposure. It is noteworthy that mindfulness practices have rapidly been integrated into trauma treatment with clients, acting as a means of grounding them in the present moment and providing a variety of anchors to stabilize them while they reprocess traumatic experiences (Follette & Vijay, 2009). The clinician’s use of mindfulness practices can similarly extend his or her ability to experience the trauma narrative and the client’s suffering without becoming identified with it, creating a more effective container for the experience for therapist and client.
It is well established that mindfulness training itself reduces stress and increases resilience in the physical and emotional arena (Baer, 2003; Grossman et al., 2004). As students identify and deconstruct their own unresolved traumatic experiences, they also become less vulnerable to being triggered by clients with similar experiences. The equanimity fostered by mindfulness practice may help to protect caregivers from compassion fatigue without sacrificing their ability to be empathic in turn. Although there are many organizational as well as individual elements to address in the prevention of secondary traumatic stress (Hesse, 2002), the self-awareness and self-care inherent in mindfulness training may make it an important protective measure on an individual level.
Burnout is a more generalized syndrome characterized by emotional exhaustion, depersonalization, and the lack of a sense of effectiveness or achievement at work (Maslach, Schaufeli, & Leiter, 2001). Like secondary traumatic stress, burnout affects a clinician’s personal functioning and clinical effectiveness; it may inspire a vicious cycle whereby a sense of exhaustion leads to withdrawal from one’s clients, a lowered sense of achievement, and, in turn, more burnout. Clinicians are also most vulnerable to burnout in the early years of practice (Ackerley, Burnell, Holder, & Kurdek, 1988; Maslach et al., 2001; Vredenburgh, Carlozzi, & Stein, 1999). Burnout itself is inversely related to longevity in the field and may be reflected in a range of stress related issues including anxiety, depression, physical exhaustion, and interpersonal fatigue (Lloyd et al., 2002; Maslach et al., 2001).
Employers are increasingly regarding mindfulness training as a means of preventing burnout out among clinicians (Hick, 2008). A recent Australian study demonstrated that psychotherapists who reported higher levels of mindfulness also reported lower levels of burnout as well as increased job satisfaction and personal well-being (May & O’Donovan, 2007). Mindfulness is thought to increase life satisfaction and well-being by helping the practitioner become more present to the joys of the moment and by reducing time spent in ruminative contemplation of the past or worry about the future. Mindfulness has been linked to increased life satisfaction, self-esteem, and an increased experience of positive emotions (May & O’Donovan, 2007). Greater levels of psychological well-being and life satisfaction among psychotherapists are in turn correlated with a robust therapeutic alliance and improved client outcome (Beutler et al., 2004). Thus, mindfulness training may be a fruitful means to prevent burnout and foster increased job satisfaction and performance among clinical social workers.