A pilot study of self-care education for psychotherapists

Abstract

Objective

Existing research shows that psychotherapists may experience secondary trauma and burnout, often neglecting self-care. This study aims to examine the effectiveness of self-care education in enhancing self-care efficacy among psychotherapists and explore factors affecting improvements in their self-care abilities.

Methods

A self-care workshop was conducted for 159 psychotherapists from various fields. Participants’ demographic information and self-care ability data were collected. The Exercise of Self-Care Agency Scale (ESCA) was used to assess the participant’s self-care levels before and after the workshop.

Results

Post-workshop, ESCA total scores and subscale scores of participants showed significant increases (all P<0.001). Notably, score improvement levels differed by gender and years of practice, with female therapists showing greater improvement than male therapists (t=2.069, P=0.040) and those with longer work experience showing greater improvement than those with shorter experience (F=2.537, P=0.042).

Conclusion

Providing self-care education for psychotherapists is essential. Future self-care education programs or interventions for psychotherapists should consider gender and work experience factors to better support their self-care enhancement.

Psychotherapists in various settings need to help clients resolve their stressors. They educate their clients about taking care of themselves but they often overlook their own self-care needs^[1].

Professionals who work therapeutically with victims of trauma are at risk for what has historically been called secondary traumatic stress (STS)^[2], also known as “indirect trauma”. On the one hand, psychotherapists need to assist clients in an open, engaged, and empathetic way. The way psychotherapists understand, experience the world and themselves is changed as they enter into the world of the clients, so they are likely to experience indirect trauma. The affected psychotherapist presents with similar symptoms to those affected by post-traumatic stress^[3]. Engaging with clients who have endured specific traumatic incidents can exert a profound and particular influence on the psychotherapists themselves. For example, working with people after traffic accidents may lead to increased anxiety about travel among the psychotherapists. On the other hand, everyone’s compassion is not unlimited. Therefore, over time, psychotherapists may experience “compassion burnout” or “compassion fatigue” which is a normal phenomenon^[4].

However, most psychotherapists may feel ashamed about such fatigue as they may view this as a sign of personal inadequacy^[5]. In addition, patients’ confidentiality makes it impossible for psychotherapists to ventilate their own feelings to their own social support network. However, when they experience negative emotions in response to indirect trauma, they may feel ashamed due to certain maladaptive beliefs about how a professional should behave. For example, they might think, “As a professional, I should be able to deal with my own negative emotions”^[6].

Indirect trauma has negative effects on psychotherapists, as well as on their family, friends, and clients. The beliefs and state of mind of psychotherapists, both conscious and unconscious, greatly influence the nature of therapy and, specifically, its outcome. If the negative effects of indirect trauma remain unresolved, psychotherapists may become ineffective in their work, make inappropriate clinical judgments, and even prematurely leave their professional careers^[7].

These problems have become more frequent and severe during the COVID-19 pandemic^[8]. Psychotherapists face additional challenges during infectious disease outbreaks, such as concerns about their own mental and physical health and that of their families, worries about the mental well-being of their colleagues, and the task of managing the distress of their patients. Therefore, self-care should be a primary concern for psychotherapists, especially during the COVID-19 pandemic. Some researchers even suggest that self-care should be viewed as a moral imperative and be included in all training and ongoing professional development programs^[9].

However, due to unique cultural characteristics, Chinese individuals, especially those in specialized professions such as therapists, military personnel, and police, tend to have a stronger sense of professional honor. This leads to a situation where individuals in these professions impose strict demands on themselves, not allowing room for mistakes. Some studies^[10-11] investigating the mental health of medical stuff in China during the COVID-19 pandemic have found that Chinese healthcare workers were usually very reluctant to receive professional psychological help, even if they admit to significant psychological stress during COVlD-19 and they did not want to openly talk about their psychological stress. As a result, issues related to burnout and self-care are rarely noticed or discussed in China. Many people may have experienced these challenges without being aware of the concepts. Therefore, understanding what self-care really is, why it is necessary, facing up to burnout without shame or remorse, and learning how to practice self-care are all topics that they are not well-acquainted with and need to explore.

The purpose of this study is to investigate whether a brief psychoeducation session on self-care could enhance the levels of self-care agency among psychotherapists and to explore demographic and other factors associated with an increase in levels of self-care agency.

1. Subjects and methods

1.1. Participants

Psychotherapists working in various settings were recruited through advertisements and social media promotions, targeting psychiatric medical staff, teachers, and employees in business corporations. Participants who took assessments both before and after the educational program were included in the study (n=159). The study was reviewed and approved by the Ethics Committee of the Second Xiangya Hospital, Central South University (20230290). All participants signed an electronic informed consent form.

1.2. Instruments

1.2.1. Demographic characteristics

Demographic characteristics were selected as study variables, including gender, age, education level, occupation, and years of work.

1.2.2. Self-care agency

Self-care agency refers to an individual’s ability to take care of their own physical, emotional, and mental well-being which is mearsured by the Exercise of Self-Care Agency Scale (ESCA)^[12]. The original scale had 43 items, including 4 dimensions. A translated version has been found to have good validity and reliability in a sample from Hong Kong^[13]. However, the 4-factor model indicates that items 4, 8, 11, 15, 23, 24, 35, and 42 had factor loadings less than 0.4. Therefore, as recommended in the paper, the remaining 35 items were divided into 4 dimensions by excluding the aforementioned 8 items, namely knowledge and information seeking (8 items), motivation (5 items), passivity (6 items), and self-concept (16 items). Our study evaluated the total score comprising all 43 items and the 4 dimensions of the remaining 35 items.

1.2.3. Satisfaction and benefit

This questionnaire was self-designed and consists of 6 questions. Higher scores indicate higher levels of satisfaction with the self-care education. There was also one open-ended question. The total score ranges from 0 to 42. The open-ended question was “What is your biggest gain from the self-care education?”

1.3. Intervention

We invited Professors Cesar A. Alfonso and Alma Jimenez from the United States to give a lecture via Zoom to the psychotherapists we have recruited. The lecture was divided into 2 parts. Part 1 discussed the concept of self-care, including “secondary trauma stress” for psychotherapists, as well as the importance and challenges of self-care for psychotherapists. Part 2 focused on solving this problem by minimizing the negative impact of stress-process aspects and implementing stress-protective measures, regulating affect, promoting healthy living, and encouraging the healthy use of technology. Since it was an online meeting format, real-time interaction with the instructor was possible, including asking and answering questions, as well as participating in discussions.

Before the beginning of the lecture, psychotherapists were asked to fill in the demographic characteristics questionnaire and the ESCA. After the lecture, they were invited to fill in the ESCA again and a satisfaction and benefit scale. The pre-assessment was conducted the day before the session began, and the post-assessment was conducted the day after the session ended.

1.4. Data analysis

SPSS version 26.0 was used for data analysis. A paired t-test was used to compare the changes in ESCA scores before and after the educational intervention. Data are expressed as $\overline{x}$ ±s. Independent t-test and one-way ANOVA were used to analyze the factors contributing to the improvement of self-care agency. All statistical tests performed were two-sided, and a significance level was set at P<0.05.

2. Results

2.1. Demographic characteristics

A total of 159 therapists participated in assessments both before and after the education program. The participants consisted of 34 males and 125 females, aged between 22 and 63 years, with an average age of (37.8±8.9) years. Table 1 presents the demographic characteristics of the participants.

Table 1.

Demographic characteristics of participants (n=159)

Characteristics	Subcategory	n	Proportion/%
Gender	Male	34	21.4
	Female	125	78.6
Age/years	≤25	16	10.1
	26-35	48	30.2
	36-45	63	39.6
	≥46	32	20.1
Education level	Doctor	8	5.0
	Bachelor	92	57.9
	Master	41	25.8
	Others	18	11.3
Occupation	Teacher	28	17.6
	Student	12	7.5
	Doctor	67	42.1
	Nurse	15	9.4
	Others	37	23.4
Years of work	<1	21	13.2
	1-10	44	27.7
	11-20	51	32.1
	21-30	34	21.4
	>30	9	5.6

2.2. Correlation between ESCA score and demographic characteristics prior to education

Before the education, the ESCA score was not correlated with demographic dimensions (gender, age, educational level, occupation, and years of work) (all P> 0.05, Table 2).

Table 2.

ESCA score before the education and ESCA score increase before and after the education based on demographic characteristics

Characteristics	Subcategory	ESCA			ESCA score increase
		$\overline{x}$ ±s	t/F	P	$\overline{x}$ ±s	t/F	P
Gender	Male	121.47±20.34	-0.764	0.446	2.21±13.34	-2.069	0.040
	Female	124.21±18.00			6.82±10.98
Age/years	≤25	119.31±11.90	1.438	0.234	5.13±6.91	0.980	0.404
	26-35	123.02±21.44			3.73±12.29
	36-45	122.29±18.23			7.51±12.30
	≥46	129.31±16.32			6.03±11.08
Education level	Doctor	131.88±19.50	1.100	0.359	3.00±10.23	0.225	0.906
	Bachelor	121.63±18.49			5.47±11.75
	Master	127.24±19.30			6.93±12.77
	Others	121.89±15.08			6.44±9.24
Occupation	Teacher	126.54±18.47	0.863	0.585	8.00±11.46	1.034	0.421
	Student	126.08±14.96			1.33±9.92
	Doctor	119.70±18.37			5.61±12.41
	Nurse	127.80±18.66			7.87±13.39
	Others	126.03±19.31			5.22±10.06
Years of work	<1	118.57±13.49	2.162	0.076	4.57±11.16	2.537	0.042
	1-10	125.61±19.70			4.07±10.08
	11-20	119.55±19.44			6.14±10.88
	21-30	128.00±17.39			10.32±12.11
	>30	132.22±15.71			-1.33±9.53

ESCA: Exercise of Self-Care Agency Scale.

2.3. Comparison of ESCA scores before and after the education

After the educational intervention, the total score of ESCA and the scores of all dimensions exhibited an improving trend, with a statistically significant difference (all P<0.001, Table 3).

Table 3.

Comparison of ESCA scores (scores of 4 dimensions and total score) before and after education

Variable	Before education	After education	P
Knowledge and information seeking	25.39±4.53	27.11±4.20	<0.001
Motivation	14.94±3.42	15.66±3.44	<0.001
Passivity	14.14±3.98	15.32±4.08	<0.001
Self-concept	49.24±7.37	50.64±7.46	<0.001
Total score	123.62±18.50	129.45±19.36	<0.001

ESCA: Exercise of Self-Care Agency Scale.

2.4. Correlation analysis between improvement of self-care and demographic characteristics

The ESCA score increase before and after the education was significantly correlated with gender and years of work (both P<0.05, Table 2).

2.4.1. Gender correlates with the improvement of self-care

The gender difference in self-care improvement showed that women had higher levels than men (P<0.05, Table 2).

2.4.2. Years of work correlate with the improvement of self-care

Multiple analyses were conducted on the increase in ESCA scores and years of work (Table 4). The scores of individuals with 1-10 years of work (Group 2) and over 30 years of experience (Group 5) increased slightly, while the scores of those with 21-30 years of experience (Group 4) increased significantly.

Table 4.

Multiple analysis of ESCA score increase and years of work

Variable	Group (I)	Group (J)	I-J	P
Difference of ESCA score before and after the education	1	2	0.503	0.868
		3	-1.566	0.598
		4	-5.752	0.071
		5	5.905	0.196
	2	1	-0.503	0.868
		3	-2.069	0.380
		4	-6.255	0.018
		5	5.402	0.198
	3	1	1.566	0.598
		2	2.069	0.380
		4	-4.186	0.100
		5	7.471	0.072
	4	1	5.752	0.071
		2	6.255	0.018
		3	4.186	0.100
		5	11.657	0.007
	5	1	-5.905	0.196
		2	-5.402	0.198
		3	-7.471	0.072
		4	-11.657	0.007

ESCA: Exercise of Self-Care Agency Scale; 1: Less than 1 year; 2: 1-10 years; 3: 11-20 years; 4: 21-30 years; 5: More than 30 years.

3. Discussion

Our study demonstrates that baseline self-care scores of psychotherapists are not related to gender, age, educational level, occupation, or years of work.

Self-care education, even in the form of a single didactic lecture, is helpful in improving the self-care scores of psychotherapists. ESCA scores improved in all 4 dimensions: Knowledge and information seeking, motivation, passivity, and self- concept after the lecture.

After receiving self-care education, the self-care scores of female psychotherapists improve significantly more than those of male psychotherapists. This is consistent with previous studies^[14-15], suggesting that female mental health professionals appear to be at a higher risk, at least for some dimensions of burnout. As they face greater difficulties, they improve more. Some studies^[11,16-17] have found that men tend to receive more tangible support, which facilitates their execution of self-care practices, while women receiving more emotional support but less tangible support. Our education may focus more on emotional support rather than tangible assistance, making it more effective for women. This highlights the importance of taking practical steps to support male psychotherapists in enhancing their self-care.

After completing their education, psychotherapists who have worked for 20 to 30 years experience the most significant improvement in self-care. Due to their extensive work experience, they have a deeper understanding of “STS”. At the same time, they are in the stage of advancing their careers, so they have a desire to seek progress and change, which was facilitated by the lecture.

Psychotherapists who have less than 10 years of work do not show significant improvement. The reason may be that they do not have enough work experience, as indicated in the response to the final open-ended question of the satisfaction and benefit questionnaire. Some psychotherapists with fewer years of work reflect, “I can only take a lot of it at face value due to lack of practice.”

Psychotherapists who have worked for more than 30 years have not improved much either. This is slightly contradictory to the previous research^[18] that “the more experience, the better the learning ability”. It is possible that individuals who work fewer hours possess a heightened drive to enhance their skills and competencies. Some psychotherapists who have worked for more than 30 years are approaching their retirement age while some may have already developed some means to cope with the stress. Besides, some of their lifestyles and thinking habits may have been solidified and are difficult to change.

It is important to note that although the participants’ ESCA scores significantly improved after just one brief lecture, this does not necessarily indicate a substantial enhancement in their self-care abilities. Rather, it suggests that they have gained a better understanding of self-care. More courses are needed to reinforce this understanding, and further long-term follow-up is necessary to confirm any actual improvements in their self-care abilities.

Furthermore, through the last open-ended question in the satisfaction and benefit questionnaire, most psychotherapists said that they ignored self-care at ordinary times and realized the importance of self-care after the education. Serveral psychotherapists have noted, “In every profession, there are elements that require safeguarding, such as the voice of opera performers, the legs and feet of ballet dancers, the fingers and hearing of pianists. But for psychotherapists, what is it that we must safeguard to ensure our ongoing effectiveness in our field? As C. R. Rogers said, ‘I have always been better at taking care of others than myself’”. Some understand and accept that “it is normal for therapists to have bad emotions when facing patients, colleagues, and themselves. We need to learn how to adjust”. Some have learned the methods and skills of self-care. The “Healthcare Workers Buddy System” was mentioned frequently. It can be seen that this has impressed the psychotherapists very much. Some expressed great interest in it and wanted to know more about it, and some believed that it is necessary to promote and implement it in China.

In summary, our study demonstrates the necessity of providing self-care education for psychotherapists. The improvement of self-care score is associated with female gender and years of work, which should be taken into consideration when planning self-care education in the future. In particular, we should select suitable and targeted training materials based on the needs and characteristics of psychotherapists. For instance, when working with senior psychotherapists, our focus should be on enhancing their enthusiasm and willingness to implement self-care practices. For junior psychotherapists, combining cases with theories can help them better understand the content. Self-care practices should be incorporated into training and ongoing professional development programs for psychotherapists. At the same time, relevant content needs to be implemented to assist psychotherapists in self-care and provide them with more practical support, such as establishing a “Healthcare Workers Buddy System”.

Availability of data and materials: The data analyzed during the current study are available from the corresponding author on reasonable request.

Funding Statement

This work was supported by the Natural Science Foundation of Hunan Province, China (2023JJ60076).

Conflict of Interest

The authors declare that they have no conflicts of interest to disclose.

AUTHORS’CONTRIBUTIONS

ZHANG Defeng Conceptualization, methodology, formal analysis, investigation, original draft writing; MA Wenjin Resources, data curation, manuscript writing, review, editing, supervision; TANG Jingqiong Project administration, funding acquisition; WU Wenjian and Manal Al-Matray Manuscript writing, review, editing; PENG Ziyu Formal analysis; YANG Huishu Investigation, validation; HONG Jiakun Investigation, data curation; ZHOU Ying and ZHAO Guangju Investigation. The final version of the manuscript has been approved and read by all authors.

Note

http://xbyxb.csu.edu.cn/xbwk/fileup/PDF/2024081301.pdf