Self Care Practices And The Professional Self

Journal of Social Work in Disability & Rehabilitation

ISSN: 1536-710X (Print) 1536-7118 (Online) Journal homepage: http://www.tandfonline.com/loi/wswd20

Self-Care Practices and the Professional Self Kendra L. Smith To cite this article: Kendra L. Smith (2017) Self-Care Practices and the Professional Self, Journal of Social Work in Disability & Rehabilitation, 16:3-4, 186-203, DOI: 10.1080/1536710X.2017.1372236 To link to this article: https://doi.org/10.1080/1536710X.2017.1372236

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Date: 04 December 2017, At: 07:00

JOURNAL OF SOCIAL WORK IN DISABILITY & REHABILITATION 2017, VOL. 16, NOS. 3–4, 186–203 https://doi.org/10.1080/1536710X.2017.1372236

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Self-Care Practices and the Professional Self Kendra L. Smith

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Department of Counseling, Gallaudet University, Washington, DC, USA ABSTRACT

KEYWORDS

Consistently and actively engaging in self-care has been shown to improve the performance of mental health practitioners by reducing burnout, vicarious trauma, compassion fatigue, and other stress-related psychological problems. Not only is this important to the individual practitioner’s well-being, but ethical standards also mandate the recognition and remediation of any physical, mental, or emotional self-impairment to maintain high standards of care for clients. Professionals in small communities, like the Deaf community, however, confront unique challenges in attending to their self-care. This article investigates these challenges—as well as the rewards—experienced by Deaf and hearing counselors working in mental health care with deaf clients.

Deaf and hard of hearing; Deaf culture; identity and belonging; lifelong learning; mental health; professionalism; service providers; strength-based perspective

Mental health professionals in small communities, like the Deaf community, confront unique challenges in attending to their self-care. This is particularly true when the professional is also Deaf. The Deaf community, comprised of diverse individuals connected by the visual nature of communication and similar worldviews rather than audiological status, has existed in the United States for more than two centuries (Leigh & Lewis, 2010). The number of mental health counselors, social workers, and psychologists who are themselves Deaf is steadily increasing (Leigh & Lewis, 2010). Although the existing self-care literature is not specific to practitioners who are Deaf or working with deaf clients, it is plausible that best practices for self-care and knowledge about working within the Deaf community will have positive results in boosting the well-being of these practitioners. This assumption is based on results for practitioners working within other small communities (e.g., rural settings, spiritual communities, and the military), as well as those practitioners working within the general population. Professionals within the fields of counseling, social work, and psychology are bound by ethical standards to monitor and maintain a level of effectiveness in their work, and to recognize and remediate any physical, mental, or emotional self-impairment (American Counseling Association, 2014; American Psychological Association, 2010; National Association of Social CONTACT Kendra L. Smith, PhD, LCPC, Professor [email protected] Gallaudet University, 800 Florida Avenue NE, Washington, DC 20002, USA. © 2017 Taylor & Francis

Department of Counseling,

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Workers [NASW], 2008). These mandates reflect the knowledge that impairment could render us unavailable—psychologically or physically—to our clients. In addition to any distress we might be experiencing in our personal lives, the very work we do can make us vulnerable to stress, burnout, and compassion fatigue. In the 16th century, Dutch philosopher Desiderius Erasmus heeded, “prevention is better than cure” (Bouch, 2011, p. 397). Although not all impairment can be avoided through prevention, there is evidence that much professional impairment can be averted through proactive self-care (Boellinghaus, Jones, & Hutton, 2013; Craig & Sprang, 2010; Finlay-Jones, Rees, & Kane, 2015; Germer & Neff, 2013; Myers et al., 2012; Shapiro, Brown, & Biegel, 2007). Once it occurs, impairment may often be effectively mediated through the application of proactive self-care, too. Self-care is a broad umbrella that encompasses diverse ongoing practices intentionally undertaken and aimed at maximizing our physical, mental, and emotional well-being. It could include practices aimed at one’s personal or professional life, or both. Although personal self-care is relevant to the lives of mental health practitioners, professional self-care is the focus of this article. Dorociak (2015) defined professional self-care as being comprised of four realms: work–life balance, psychological health, professional development, and professional support. Work–life balance refers to behaviors we use “to create a positive and supportive work environment, to manage work and time pressures, and to maintain boundaries between work and family life” (Dorociak, 2015, pp. 25–26). The psychological health realm involves emotional and cognitive stability and is enhanced by resilience in the face of workplace stress.1 The professional development realm recognizes the value given to maintaining a passion and sense of purpose for our work, the continuous improvement of skills and knowledge, and the advancement of our career throughout the span of our professional lives. Professional support involves fostering an interpersonal support system within our workplace and with other colleagues in our broader work world. The need for professional self-care is evident in the literature. Significant stress-related psychological problems have been reported in numerous studies focused on mental health professionals, including depression, anxiety, disrupted relationships, and reduced self-esteem (Boellinghaus et al., 2013; Finlay-Jones et al., 2015; Shapiro et al., 2007), as well as vicarious traumatization, compassion fatigue, and burnout (Craig & Sprang, 2010; Merriman, 2015; Richards et al., 2010; Shapiro et al., 2007; Sprang, Clark, & 1

Ironically, we often see ourselves as impervious to psychological stresses because we, after all, are the “authorities” in promoting psychological well-being in other people. However, substantial evidence indicates our vulnerability to psychological stress and illness is at least equal to that of the general population (e.g., Craig & Sprang, 2010; Lim, Kim, Kim, Yang, & Lee, 2010; Linley & Joseph, 2007; Richards, Campenni, & Muse-Burke, 2010).

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Whitt-Woosley, 2007; Ying, 2009). For example, Finlay-Jones et al. (2015) found in a review of the literature that as many as 40% to 73% of psychologists and trainees reported distress at levels that would warrant treatment. The general self-care literature for mental health professionals reflects “both the unique demands of psychological work and the demands of trying to balance work and personal life in designing interventions and in offering recommendations for engaging in self-care” (Dorociak, 2015, p. 79). As professionals, our work exists within a feedback loop in which our level of well-being directly influences our ability to support our clients, and our feelings of efficacy about our work with clients, in turn, influences our level of well-being (Lim et al., 2010; Sprang et al., 2007). However, we cannot rely on our clients as the appropriate or available source for helping us feel our work is affirmed, recognized, accepted, or appreciated. Thus, we need to develop practices for self-care that go beyond satisfaction derived from the therapeutic work.

Self-care considerations for mental health practitioners in the Deaf community Deaf people are members of a cultural and linguistic minority. The experience of being Deaf is not disabling, but living in a nonsigning, audiocentric world can be (Whyte, Aubrecht, McCullough, Lewis, & Thompson-Ochoa, 2013). Individuals who identify as members of the U.S. Deaf community are geographically dispersed and diverse in terms of race, ethnicity, religious beliefs, and educational background. Yet the common denominators of language, history, customs, arts, and literature, as well as the collective experiences of marginalization, create a strong bond among community members (Eckert & Rowley, 2013; Whyte et al., 2013). As with other closeknit communities, the social support provided within the community leads to high levels of satisfaction among those who adhere to community standards. Thus, upholding the responsibilities of one’s membership is seen as vitally important to maintenance of the community and the individual’s well-being. The Deaf community relies on tight-knit community relationships supported by ties to the community that could extend over multiple generations, including attending the same schools and churches, and participating in local deaf clubs and organized adult athletics (Leigh & Lewis, 2010; Whyte et al., 2013). These strong social ties result in a fictive kinship bond, wherein people are considered part of one’s “family” even though they are not related by blood or marriage bonds. In addition, Deaf people commonly marry other Deaf people or hearing members of the Deaf community (e.g., adults with Deaf parents or siblings), resulting in a community with strong familial kinship as well (Padden & Humphries, 1990).

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It is common for Deaf people, much like people from indigenous cultures, to be actively connected with close friends and family in other towns and states. Deaf social events can draw people from as far as thousands of miles away (Guthmann & Sandberg, 2002). Information relevant to the community is shared freely across the miles, too—particularly in the current age of smartphone technology and the Internet. Behnke (2008) described a similar phenomenon in Hawaii, affectionately referred to as the “coconut wireless,” wherein information is gathered and disseminated quickly among the native island communities. This interconnected and interdependent nature of the community is vital for growth and survival of its members. Mental health professionals working in the Deaf community, whether Deaf or hearing, are subject to the same social responsibility and affiliate support within the community just described, and might have family ties in the community as well. For this reason, professional self-care must include considerations related to small community membership. For example, the free-flowing nature of communication and its inherent reduction in privacy creates frequent opportunities for professionals to make ethical choices about maintaining a separation between their professional and personal lives (Guthmann & Sandberg, 2002). The following sections investigate the four realms of professional self-care as they pertain to mental health professionals in the Deaf community. Work–life balance

The ethical standards of the professional mental health associations (i.e., American Counseling Association, 2014; American Psychological Association, 2010; NASW, 2008) caution professionals to avoid dual or multiple relationships with clients. Confusion about role boundaries and the power differential between counselor and client could harm the client. “Dual or multiple relationships occur when … [mental health professionals] … relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively” (NASW, 2008, section 1.06). Likewise, in various sections of the American Counseling Association (2014) Code of Ethics, counselors are prohibited from engaging in counseling relationships with friends or family members, are prohibited from engaging in virtual relationships with current clients through social and other media, and are cautioned to give careful consideration before accepting as clients those with whom they have had a previous relationship or when extending the current counseling relationships beyond conventional therapeutic boundaries. Examples given of the latter are attending a client’s graduation or wedding or commitment ceremony, purchasing a service or product of the client, or visiting a client’s ill family member in the hospital. Additionally, counselors should avoid entering into nonprofessional

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relationships with former clients, clients’ romantic partners, and clients’ family members when the interaction is potentially harmful to the client. Although we are cautioned to avoid multiple relationships with clients, in the Deaf community, as in other small communities (e.g., rural settings, the military, and spiritual communities), relationships based on multiple roles are inevitable. Mental health practitioners in the Deaf community are likely to have prior social connections with their clients outside of the context of the therapeutic relationship—for example, as coaches, friends, colleagues, or teachers (Guthmann & Sandberg, 2002). They might also know, or have worked with, other members of the client’s family. This is similar to psychologists working in rural settings, about whom Behnke (2008) reported there are, at most, two degrees of separation, not the six degrees of popular culture. For this reason, mental health practitioners must remain mindful of whether information about the client came from within the therapeutic relationship or was gained in a separate social context. Although some might interpret these challenges as potentially onerous, working in a small community can conversely be seen as having a richness not found in other work settings (Behnke, 2008). This turning of the lens away from a deficit perspective toward one of complexity and vibrancy reflects an appreciation for the cultural competence of mental health professionals (also mandated by ethical standards) who practice in close-knit communities as they adapt to the circumstances and challenges that are inherent in the work. A culturally competent therapist working in the Deaf community recognizes that maintaining the traditionally more detached role when working with deaf clients has a different, often negative, impact than in the hearing population (Guthmann & Sandberg, 2002). For example, Deaf clients often “seek out professionals because they are known and not complete strangers” (Guthmann & Sandberg, 2002, p. 292). A therapist with more rigid boundaries might be considered unapproachable, or as showing superiority, coldness, and disinterest. Cultural awareness enables us to understand that the formation of trust in the counselor–client relationship is, for some Deaf clients, highly dependent on our full participation as community members. For therapists who are Deaf or have Deaf family members, prohibiting nonprofessional relationships with clients could lead to personal and social isolation, exclusion, and disconnection (Behnke, 2008; Leigh & Lewis, 2010; Smith, 2007). Such a stance might lead to unnaturally limiting their circle of friends and acquaintances; avoiding social events; not attending their children’s school, sporting, and social activities; and avoiding many business meetings, conferences, and other opportunities for professional development lest they have interactions with clients. Yet we know from the self-care literature that maintaining an active, positive social life and engaging in sports and hobbies are some of the vital components for increasing overall well-being and reducing the risk of professional burnout.

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Self-care for the mental health professional working in the Deaf community must include the ability to navigate culturally appropriate boundaries, not only with community members, but also between personal and work roles. In this capacity, self-care means attending to both your professional and personal self. Instead of trying to shoehorn our lives into the deficit-based perspective of a professional role, we can embrace the reality of overlapping relationships and be prepared to manage them. For example, we can compartmentalize roles, not relationships. To achieve this, we need to establish a clear separation between the different roles we hold, while maintaining a consistent authenticity and interpersonal style. When the occasions arise that we have multiple roles or relationships with a client, we are advised to monitor our personal and professional needs, not lose sight of the possible influences on the lives of our clients, and consult with professional colleagues and supervisors (Barnett & Yutrzenka, 2002; Bradley, Ladany, Hendricks, Whiting, & Rhode, 2010). The latter can ensure we do not “rationalize, deny, or trivialize potential harm or exploitation that might occur from dual relationships” (Barnett & Yutrzenka, 2002, pp. 282–283). Family members of mental health professionals in the Deaf community might need guidance about how to handle situations arising from the work of the professional. In a qualitative study of psychologists working in rural settings, researchers found that the psychologists “tutored” their children about how to handle questions from others about the parent’s work, how to use appropriate self-disclosure (given that the children do not know who might be the parent’s client), and how to manage confidential information —acquired inadvertently or otherwise (Schank & Skovholt, 1997). This preparation helped family members participate in vital interpersonal connectedness within the community while recognizing the expectations for privacy and understanding the complexity of multiple roles. Despite dual relationship challenges, many Deaf mental health professionals report that it is possible to maintain a full and healthy social life in the Deaf community while working in the same community (Leigh & Lewis, 2010; Smith, 2007). Not surprisingly, growing up in this interconnected and interdependent community has already equipped Deaf professionals with the tools needed to face the challenges of maintaining some separation between work and personal life. In a qualitative study, deaf participants reported that even before becoming counselors, they had learned to manage multiple roles with finesse by watching parents, teachers, and other Deaf role models, and through their own “trial and error” experiences in childhood and adolescence (Smith, 2007). Psychological health

One essential ingredient of positive sociopsychological health is successfully integrating a positive personal identity with a positive professional identity.

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Achieving a positive personal identity is often a significant challenge for deaf individuals in an audist society.2 Gertz (2008) coined the term dysconscious audism to describe the phenomenon wherein deaf people internalize some of the antithetical values from the dominant hearing culture, resulting in an incompletely developed consciousness about their identity. In other words, they feel the need to assimilate into the mainstream culture, even though that culture is rife with oppressive attitudes and behaviors toward them. Dysconscious audism could also be present in Deaf mental health professionals, thus influencing their work. Unresolved issues surrounding the positive internalization of a Deaf identity might result in pathologizing their deaf clients in ways similar to that of the majority hearing society. Even Deaf therapists with positive, well-integrated identities could encounter countertransference in their work. For example, it is not unusual for a Deaf therapist who has experienced years of discrimination and marginality to overidentify with his or her deaf client’s experiences of the same (Leigh & Lewis, 2010; Smith, 2007). Professional marginalization also occurs for deaf therapists. In one study of Deaf counselor professional identity, Deaf participants reported finding it challenging to develop a positive professional relationship given the prevailing cultural centrism of the counseling field (Smith, 2007). Specifically, the study participants felt their Deaf culture and language were grossly underrepresented in professional matters, including research, publications, workshops, and conferences. Pollard (1996) reported on the experiences of deaf psychology trainees who were not accepted at internships with agencies that specialize in treating deaf clients: It has long been an odd but ubiquitous circumstance that researchers and practitioners working across cultural and language boundaries with minority individuals or other stigmatized populations, such as persons with disabilities, associate those populations with intellectual and psychological infirmity, which makes working with them an act of benevolence, but working beside them an act of condescension. (p. 393)

The dissonance created in these professional experiences—whether as dysconscious audism or countertransference—can lead to depression or anxiety, and could contribute to professional burnout (Smith, 2007). Confidentiality of client information also poses challenges to the mental health professional’s ability to “offload” work-related stress. Deaf counselors have reported that they cannot talk about their work with partners, spouses, family members, or friends in even the most vague terms because incidental information can lead to the confidante identifying the client (Smith, 2007). 2

Audism refers to a “schema of audiocentric assumptions and attitudes that are used to rationalize differential stratification, supremacy, and hegemonic privilege” based on one’s ability to hear (Eckert & Rowley, 2013, p. 105). For a detailed description of how audism manifests in theory and practice, see Eckert and Rowley (2013).

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Other job-related psychological stressors are experienced by Deaf and hearing mental health professionals alike. As noted earlier, the nature of our work involves “holding” our clients’ suffering. Multiplied by the number of clients in our caseload, the amount of suffering we contain—even temporarily—for others can add up quickly. Additionally, clients often present symptoms of chronic psychological disorders; our progress with these clients can be slow and difficult, requiring us to measure “success” over years, not minutes or days (Craig & Sprang, 2010). Because we cannot rely on our clients as the appropriate or available source for helping us feel our work is affirmed, recognized, accepted, or appreciated, job satisfaction might wane and push us toward burnout and compassion fatigue (Lim et al., 2010; Sprang et al., 2007). Burnout

Burnout is “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment, characterized by cynicism, psychological distress, feelings of dissatisfaction, impaired interpersonal functioning, emotional numbing, and physiological problems” (Sprang et al., 2007, p. 260; see also Lim et al., 2010). Burnout results from workplace characteristics, like caseload size, perceived lack of support, and institutional stress (Sprang et al., 2007). Interestingly, burnout is typically reported at higher rates by mental health professionals working in agency settings, as opposed to those working in private practice settings. Lim et al. (2010), for example, found a strong correlation between working in agency settings and emotional exhaustion and depersonalization. They attributed this to large caseloads, a perceived lack of control in selecting clients, and administrative decisions based on the fiscal aspects of therapy rather than the therapeutic relationship. This frequently leaves the therapist to negotiate between which treatment is necessary and that for which insurance, Medicaid, or Medicare will pay. In the Smith (2007) study, most Deaf counselor participants reported high levels of burnout. This is likely due to many of the reasons given in the preceding paragraph, plus some unique factors. First, living and working in a small community, the counselor is always “on the job”—recognized 24/7 in his or her professional role, with no time off to step away from the professional standards expected of him or her by the community (Cohn & Hastings, 2013; Smith, 2007). Second, deaf consumers have relatively few treatment options, given there is a paucity of mental health professionals in the United States who are fluent in sign language and are culturally competent. Therefore, mental health professionals who are linguistically and culturally competent must be generalists in practice, “expected to function more broadly than the role traditionally accorded their discipline (such as psychology, social work, or counseling), and expected to work with

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clients with all kinds of problems in all kinds of settings” (Gutman, 2002, p. 21). This can contribute to emotional exhaustion. Being a generalist is not always a negative thing, though. Flexibility in scope of practice can reduce boredom and dullness borne out of routine (Craig & Sprang, 2010). Deaf counselors in the Smith (2007) study also reported a lack of control over the discrimination and bias they experienced themselves as deaf persons; this was no different when in their counseling role. Shared lived experience, isolation, lack of validation, racism, and lack of acceptance by other professionals in their field were reported as contributing factors for burnout in mental health professionals who are also members of culturally marginalized groups (Smith, 2007). Mental health professionals—whether Deaf or hearing—who work with deaf clients also spend greater amounts of time advocating on behalf of their deaf clients within the educational, medical, and public assistance systems (Smith, 2007). Issues ranging from insurance approval for services outside of network (often required when requesting a provider fluent in American Sign Language [ASL]) to finding suitable group home placements, to referral for culturally appropriate diagnostic and treatment services, are often confusing and exhausting for the client, particularly in combination with any existing psychological disorders or learning and language challenges (Smith, 2007). As a result, it is not unusual for therapists to provide extensive case management support by engaging with these systems on behalf of the client. These activities could prove to be confusing, frustrating, and exhausting for the therapist, too. Compassion fatigue

Also called secondary traumatic stress, compassion fatigue is defined as the “transformation of cognitive schemas and belief systems as a result of empathic engagement with survivors of traumatic experiences” (Craig & Sprang, 2010, p. 320). Given the empathic nature of our work, it is not surprising that compassion fatigue is one of the inherent occupational hazards we face as mental health clinicians. Compassion fatigue can create disruptions in our “experiences of safety, trust, power, esteem, intimacy, independence, and control” (Sprang et al., 2007, p. 260). Symptoms of compassion fatigue include anxiety, disconnection, avoidance of social contact, becoming judgmental, depression, somatization, and disrupted beliefs about self and others (Sprang et al., 2007). For Deaf therapists, the vulnerability for compassion fatigue goes beyond the level expected for professionals working on the frontlines in treating trauma because much of the clients’ trauma is rooted in the experiences of being deaf in a hearing-centric society. Empathic engagement can lead to overidentification with the traumatic material presented by deaf clients.

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It is important to note that compassion for our clients is not always a cause of distress. Therapists can also experience compassion satisfaction—the pleasure one derives from being able to do his or her work effectively (Craig & Sprang, 2010). There is some evidence that compassion satisfaction increases with years of professional service, indicating that experience might be a buffer against the negative effects of exposure to client trauma. Specialized trauma training has also been shown to increase compassion satisfaction in national samples of mental health practitioners, most likely due to enhancing the clinician’s self-efficacy (Sprang et al., 2007).

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Limited access to counseling services

No discussion of psychological health and self-care can be fully understood for Deaf therapists without also recognizing the challenges they have in seeking their own therapy. Deaf therapists have reported that they do not want to receive mental health support through an interpreter from a therapist who does not know sign language, yet they are often reluctant to receive services from ASL-fluent therapists who are part of their own professional network (Leigh & Lewis, 2010; Smith, 2007). Referring clients to and receiving their own therapy services from the same clinicians reportedly felt awkward, and frequently resulted in Deaf mental health professionals not seeking the support they needed (Smith, 2007). This lack of personal counseling services thus might become an additional stressor for therapists. Professional development

Professional growth and development is essential to professional self-care. The usual avenues for this (i.e., workshops, classes, and conferences) are often not accessible to Deaf counselors due to language barriers. Smith (2007) found that Deaf counselors frequently felt excluded and unwelcome at professional events hosted by hearing organizations. This author has collected a substantial amount of anecdotal evidence that professional organizations are reluctant to hire qualified interpreters (citing reasons of affordability), and even when interpreting services are provided (e.g., at the American Counseling Association annual conference), they are usually provided only for presentations, not for social or networking time with other conference or meeting participants. Advocating for equal access is an additional burden the Deaf professional must bear. Professional involvement can be an important means of maintaining one’s identity despite a demanding job (Cohn & Hastings, 2013). However, therapists working with deaf and hard of hearing clients have reported that when they attend these conferences, the content material often does not address the unique cultural considerations of their client population. There are few

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professional organizations that focus on mental health services within the Deaf community, and those that do exist are not adequate to meet the wide range of professional growth and training needs of today’s mental health provider.

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Professional support

Professional support involves fostering an interpersonal support system within our workplace and with other colleagues in our broader work world. Literature about the quality of the work environment of mental health providers who serve the Deaf community is scarce. However, Smith (2007) found that the quality of work relationships for Deaf counselors was substantively significant. Connectedness, cooperation, and respect are Deaf cultural norms that, when absent, can have a negative effect on satisfaction with the work environment. Relationships with Deaf coworkers can be positive, and include feelings of mutual respect in areas of skill, knowledge, ethics, and rapport. Deaf counselors have reported, however, that relationships with hearing peers and administrators varied depending on the cultural and linguistic competence of the hearing professional (Smith, 2007). The behavior of hearing peers and administrators often resulted in the Deaf counselors feeling left out and not valued, and caused them to wonder if they were missing out on important information that could affect work performance. Even considering the larger work world (outside of the immediate work environment), professional peers—Deaf or hearing—who are trained to provide culturally and linguistically appropriate services within the Deaf community are small in number. Therefore, building coalitions of support with other providers is often a challenge. Professional connections in the deaf community, though, are long-lasting and typically span across long distances (Leigh & Lewis, 2010). The “two degrees of separation” mentioned by Bouch (2011) enables mental health practitioners to reach out for support to others in their work world that they might not yet know directly. As in rural communities, “there are many opportunities for meaningful collaboration with physicians, attorneys, and other professionals whose roles interface with the counselor’s. Clinicians describe these collaborations as energizing in that they provide new perspectives, new challenges, and new opportunities for practice” (Cohn & Hastings, 2013, p. 232). The same might be true for clinicians in the Deaf community, particularly given the norms associated with connectedness and collaboration in the community. Self-care practices Self-care involves attending to one’s mental, physical, emotional, and spiritual needs and, when practiced consistently, can improve one’s overall sense of

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professional well-being, as well as reduce the prevalence and effects of burnout and compassion fatigue (Baldini, Parker, Nelson, & Siegel, 2014; Brucato & Neimeyer, 2009; Cohn & Hastings, 2013; Richards et al., 2010). The benefits of self-care are so widely recognized that many mental health degree programs have incorporated practitioner wellness and self-care into their teaching curricula (Boellinghaus et al., 2013; Merriman, 2015; Neff & Germer, 2013; Shapiro et al., 2007; Ying, 2009). Although students in training programs might not yet have experienced professional burnout, they are often vulnerable to the stress and emotional exhaustion associated with the rigors of their academic programs. The curricular emphasis on developing cultural competence requires students to be highly introspective and might require students to challenge their preexisting worldviews, thus creating a temporary sense of disequilibrium or psychological distress (Ying, 2009). Incorporating experiential learning about self-care into the curriculum not only gives students tools with which to manage this distress, but also helps to establish a pattern of protective practices at the start of their career. A review of the literature found nothing on self-care practices specific to Deaf or hearing clinicians working with deaf clients. However, this article has already established links between work in the Deaf community and other small communities that could be extended to include the value of self-care practices. The choice of self-care practice is largely personal, but empirical evidence is emerging on the benefits to clinicians of engaging in personal therapy, supervision, professional training, spiritual practice, and selfcompassion. Personal therapy

Personal therapy can be a powerful intervention to support the work–life balance and psychological health realms of self-care. It is strongly associated with positive psychological changes (e.g., reductions in depression and anxiety) and less burnout for mental health practitioners (Linley & Joseph, 2007; Richards et al., 2010). Engaging in our own therapy helps us to increase self-awareness and understanding, and further develop empathic skills for both self and others. It also improves our ability to identify and maximize our strengths and work with our limitations, while developing more awareness for establishing and maintaining good boundaries between work and personal life. Therapy can help to examine work-related stress and residual client trauma we continue to carry around with us, as in the case of Deaf mental health professionals who might need to process their countertransference experiences. There are obstacles for Deaf practitioners in finding culturally and linguistically appropriate therapy due to, among other reasons, the small number of qualified therapists available, awkwardness in receiving therapy

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from colleagues, and geographic isolation. The advent of distance counseling services via videophone has helped increase accessibility to therapy services. Although the Deaf counselor seeking services might know the distance provider and they might have occasion to bump into each other at professional trainings or large Deaf social events, having the therapist located at some geographic distance does permit a modicum of privacy (e.g., for participating in social activities in the hometown area).

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Supervision and professional training

Clinical supervision is also an appropriate venue for exploring countertransference and other job stressors. The clinician’s personal and professional development—both interdependent—are considered primary tasks of supervision (Bradley et al., 2010). “Damage to, or facilitation of, either one has a reciprocal effect on the other” (Bradley et al., 2010, p. 7). Benefits from supervision toward well-being include developing an increased sense of self-efficacy and competence, and a reduction in professional isolation. Supervision for clinicians working in the Deaf community can be extremely helpful to the clinician in making choices about management of boundaries and multiple role relationships. Continued professional training is another means to increase self-efficacy and competence, thereby reducing burnout and compassion fatigue. For example, trauma workers experience less secondary stress reactions and higher compassion satisfaction when they receive specialized trauma training (Sprang et al., 2007). Because professional development activities involve interactions with peers, colleagues, mentors, and supervisors, activities such as conferences, workshops, and practice consultation groups can create opportunities for attending to the professional support realm of self-care as well. Spiritual well-being

The spiritual component of self-care is an internal set of values that provides meaning to life, an inner wholeness, and a connection with the universe. As such, it permeates all four realms of professional self-care. For some, spirituality is entwined with religion, whereas for others it might be comprised of meditation, art, nature, or other practice that transcends the material aspects of life with the goal of finding meaning. Positive thoughts and optimism are components of spirituality, and both have been shown to strongly correlate with well-being and resistance to stress (Myers, Sweeney, & Witmer, 2000). Contemplative practice is one expression of spirituality. Examples of contemplative practices are meditation, yoga, walking the labyrinth, reading poetry, and silent retreats. Mindfulness meditation is a specific type of

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meditation that fosters moment-to-moment awareness of our experience and heightens our capacity to attend to the experience—whether positive or negative—in an open, nonjudgmental manner. Over time, the practice of mindfulness meditation reduces our overidentification with self-focused thoughts and emotions that can lead to poorer mental health and professional emotional exhaustion (Shapiro et al., 2007; Ying, 2009). Equanimity and clearer perspective, obvious factors in self-care, can be achieved when we avoid ruminating on negative feelings through mindfulness meditation (Germer & Neff, 2013). Practicing mindfulness helps build connections between different regions of the brain, resulting in, among other things, emotional well-being (Baldini et al., 2014). For the mental health practitioner, these integrative brain connections mean becoming more resilient and effective in clinical practice through improved psychological health, reduced burnout, and enhanced capacity for therapeutic relationships (Baldini et al., 2014). The practice of mindfulness has another significant benefit for mental health practitioners —namely, it helps increase our perceived value of self-care, which in turn increases overall well-being (Richards et al., 2010). In a profession that attracts people who often put the care of others before that of ourselves, raising the value of self-care is crucial. Kabat-Zinn (1982) used the principles of mindfulness meditation to develop mindfulness-based stress reduction (MBSR), which is perhaps the most widely known and practiced stress reduction program in the United States in the last quarter-century. MBSR was initially developed by Kabat-Zinn (1982) as a means to address chronic physical pain in patients who could not find relief in any medication or medical procedure. MBSR has since been shown to be effective at enhancing well-being in individuals with a variety of medical and psychiatric conditions. Pertaining to mental health practitioners (and graduate students in the helping fields), research has found MBSR decreases perceived stress, negative affect, state and trait anxiety, and rumination, and significantly increases positive affect, selfcompassion, and therapeutic presence (Keng, Smoski, Robins, Ekblad, & Brantley, 2012; McCollum & Gehart, 2010; Shapiro et al., 2007). Self-compassion

Compassion, in general, means having kindness for living beings that are suffering and the concomitant desire to ameliorate their suffering (Neff, 2003). Compassion is usually described directionally; that is, compassion toward others, compassion from others, and compassion toward oneself. A growing body of evidence indicates that self-compassion is a key factor in promoting positive psychological outcomes such as happiness, optimism, contentedness, wisdom, emotional intelligence, and adaptive emotion

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regulation in times of stress (Finlay-Jones et al., 2015; Germer & Neff, 2013). This could be due, in part, to deactivating the internal threat system and activating the internal caregiving system “associated with feelings of secure attachment, safety, and the oxytocin-opiate system” (Germer & Neff, 2013, p. 858). Neff (2003) identified three core components of self-compassion: selfkindness, acknowledgment of a common humanity, and the practice of mindfulness. These components interact to create a self-compassionate frame of mind. Working from this mindset helps us to temper our negative response to personal inadequacies, mistakes, and failures (Germer & Neff, 2013). Self-kindness is “the tendency to be caring and understanding with oneself rather than being harshly critical” (Neff & Germer, 2013, p. 28). It is practiced through engaging in self-soothing and positive self-talk. Even when we recognize that certain unproductive behaviors need to be changed, selfkindness offers unconditional acceptance and warmth, and leads us to comfort ourselves before trying to control or fix our problems. For mental health practitioners, this is particularly helpful when we experience emotional reactivity to client material and when we are faced with real or perceived professional failure. The second component of self-compassion is the recognition that our discomfort is an unavoidable part of the human experience, thereby promoting a sense of connection to others rather than increasing our sense of isolation and despair. Imperfections are not an anomaly; they are part of the human condition (Germer & Neff, 2013). For mental health practitioners, this serves as a reminder that failure and imperfection are to be expected in our professional pursuits, too. The acknowledgment of “common professional humanity” can be fostered through supportive professional relationships with colleagues, supervisors, and mentors. Mindfulness was covered in the previous section on spirituality, however, in Neff’s construct of self-compassion, mindfulness specifically draws attention to “turning toward our painful thoughts and emotions and seeing them as they are—without suppression or avoidance” (Germer & Neff, 2013, p. 857). This reduces our overidentification with self-focused thoughts and emotions. For the mental health practitioner, mindfulness can provide a way to acknowledge and address the painful thoughts and emotions associated with countertransference and “holding” traumatic client material. Fortunately, unlike self-esteem, self-compassion is something we can learn to practice (Merriman, 2015; Neff & Germer, 2013; Ying, 2009). Specific activities that promote self-compassion include self-affirmations, expressions of gratitude toward oneself, allowing time to pause and “check in” with ourselves on thoughts and emotions, reevaluating our expectations for work, and practicing meditation or guided self-reflection.

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Conclusion Self-care is a professional mandate for social workers, counselors, and psychologists. Stress is inherent in our work and our ability to cope with it can be diminished under certain circumstances (e.g., working with trauma survivors or within nonsupportive settings). Unresolved stress can surface as burnout, compassion fatigue, or other psychological distress and illness, and could have adverse effects on our ability to perform and experience satisfaction in our work and personal lives. In particular, there are unique stressors for mental health professionals who work within close-knit communities, like the U.S. Deaf community. The good news is that we can counter stress by attending to the four realms of professional self-care (work–life balance, psychological health, professional development, and professional support) through the specific self-care strategies outlined in this article. The key is to be intentional in devoting time to self-care practices. Knowledge is simply not enough. To be effective, selfcare has to be more than an intellectual exercise. We must be kind enough to ourselves to actually do it! Acknowledgment Appreciation is given to Dr. Mary C. Hufnell who contributed to earlier dialogues that informed the content of this article.

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