Balance Over Burnout for Mental Health Professionals

Editor's Note: This text-based course is a transcript of the webinar, Balance Over Burnout for Mental Health Professionals, presented by Khara Croswaite Brindle, MA, LPC, ACS, CFT-I.

Learning Outcomes

• After this course, participants will be able to identify the symptoms of burnout.
• After this course, participants will be able to explain self-care strategies for successful restoration for professionals within the mental health field.
• After this course, participants will be able to create a wellness plan against burnout.

Introduction

We will talk about burnout, prevention, and signs of burnout. It will be wonderful, and I know it is very applicable to everyone watching this presentation. You will be able to create a wellness plan against burnout. You will have some tangible tools that will help you and the clients you serve. What I love about this presentation is not only are you getting tools for yourself, but for any professional you might be serving who is experiencing burnout, these tools are also applicable to them.

Limitations and Risks

• Limitations include a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privilege.
• Risks include 1) presented strategies impacting self of therapist where additional support could be helpful. 2) These strategies are not a one-size-fit all approach and do not substitute your own work.

Limitations include that this is a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privileges—recognizing that for a lot of people, burnout recovery is, in fact, about having resources and being able to do something, in particular, to get out of burnout. It does not happen. There has to be some intentionality there. Risks include presented strategies impacting the self of the therapist where additional support could be helpful. By no means, by taking this training, will you have yourself recover from burnout. That would be wonderful, that would be amazing, but for today, we want to make sure that you have the strategies to implement, knowing that you probably have some more work to do if you resonate and realize that you might be in your burnout journey.

These strategies are not a one-and-done, are not a one-size-fits-all approach, and do not substitute your work. Hopefully gives you a sense of direction for yourself, but if you do find yourself in burnout currently or somewhere in the future, these are not the one thing that is going to get you out of burnout. This is the start of the journey, not the end.

Flossing

Burnout recovery is like flossing. Why? How could that possibly be? is what you might be asking yourself. How is burnout recovery like flossing? Well, let's think about it. Flossing is something that we are told to do. We are told it is important. We are told that a long-term strategy is good for our health. Burnout, recovery, and self-care is the other part of this combination. Also, when you ask people honestly how often they floss, they are like, "Eh, maybe not very often. Maybe right before my dentist appointment. Maybe like the month before I am supposed to be seen. Maybe it is sporadically when I remember or have time."

Flossing itself feels like effort, which is for a lot of you. Burnout and burnout recovery, burnout prevention and recovery feel like effort. Maybe when you think about burnout and self-care, you feel like a cringing person. "Ew, I do not like to do this." Versus someone who is like, "I have got this down. This feels good to me." 

In the long run, it is good for our health. Obviously, most of us want to avoid burnout but recognize that it is possible in our mental health profession. Burnout recovery is like flossing. It takes effort. It requires some repetition and self-care practice, which we will cover in today's presentation. As you think through some of these things, you will continue to have a reflection, something to pause and think about.

Self-Reflection #1

• What puts mental health professionals at greater risk for burnout?

Self-reflection number one asks what puts mental health professionals at greater risk for burnout. Thinking to yourself, what shows up? What would your answer be? Is it the possibility of vicarious trauma for mental health professionals? Is it compassion fatigue? Is it directly related to the population that we serve? If we are working with people who have had significant trauma, are we more likely to put ourselves into burnout? These are questions that might be coming up for you. It might not surprise you that 75% of working Americans feel like they have already experienced signs or symptoms of burnout while in the workplace, 75%. That is not even mental health professionals. That is across the whole American workforce. Burnout is common and is on the rise as we come out of a pandemic and build a new life. What puts mental health professionals at much greater risk? For some of you, it is everything you give to your clients and the fact that you want them to be healthy and do well and that you want them to succeed. That comes at a cost, which might be our health and wellness as we look at this further. Notice what comes to mind as you see this question and how you might respond.

Overview

• Burnout
• Values
• Self-Care
• Wellness Plan

Today's presentation will cover four topics: burnout, values, self-care, and a wellness plan. As we started to talk about already, we are looking at burnout prevention, but all four of these exercises are going to hopefully help you in either burnout prevention or burnout recovery, depending on where you are in your professional journey.

The first exercise to introduce to all of you is values. If you have had a values exercise, you might have had it in undergrad and grad school as part of a psychology course, or as a mental health professional, you might have introduced a values exercise to your clients because it can be a very powerful tool. For some of you, this might look familiar. For others, it might be completely new. All of the exercises from today's presentation have handouts attached to them. You will have access to those.

Exercise #1 Values

For right now, let's look at them here. There are about 40 values here in Figure 1.

Figure 1. Forty values from https://www.leadingfromwithin.net.

If you were to complete this exercise, the first thing I would have you ask yourself is, what value describes you as an individual? Looking back at this list, most people must start by narrowing down all these values. Your first task might be to narrow down your top 10 values because this is quite a list. From there, maybe you have a strategy to get down to your top five, then your top three, and then your top one.

Values and Burnout

• Think about what value describes you as an individual.
• What value describes you in your career?
• What value would you like to strengthen or improve?

What is a value that describes you as an individual? In my experience administering values exercises for the last decade, I will say that most people's values do not change significantly as they age. Maybe you have done a values exercise before and recall what those values showed up for you.

They tend not to change very often as you get through your lifespan. Thinking again, what value describes you as an individual? Is that value different from than one that describes you in your career? For example, as an individual, your top value is personal growth, but then in the workplace or in your career, it is maybe education is important to you. Recognizing how those differ in your individual life and your professional life. The third one to think about is what value you would like to strengthen or improve. Is it one of the two you have already named, as our example, personal growth versus education, or is there a different value that you would like to strengthen or improve?

Self-Reflection #2

• What are your top three values?

As you think about your top values and identify those top two or three, there is an overlap for many people. Even when you look at this full list, there are things that you might say, "Oh, I can say that both are important," but pick one to narrow it down. That is one strategy. For today's example, let's say personal growth versus education. Maybe for that third question, I say, "I want to strengthen leadership." As you start to notice those, how does that contribute to your burnout? If personal growth is important to you as an individual and education is important to you in your career, is it possible that they contribute to your burnout somehow?

Are you pushing yourself in an educational space to take on more than you can hold? Are you trying to pursue multiple degrees at once? Are you taking on a dozen pieces of training as a mental health professional? Notice how that might show up as part of your top value of education. Do you feel you always have to learn something and push for personal growth? Are you doing your therapeutic work as you support other clients in their mental health work? How does that contribute to burnout for you? Remain curious as you do this exercise to see how that might contribute to your burnout or burnout recovery. As we started to think about it, name what your top three values are now.

The examples I gave today personal growth, education, and leadership. If leadership is the one I want to strengthen, what does that imply when it comes to my burnout journey? Are your top three values showing up in your life right now? If we take this to the next level, what happens or what does it mean to you if your values are absent or neglected? If my top value is personal growth, but I have not done anything to feel like I am growing in the last year, how could that impact me? If I think leadership is important, but I have not done anything in the leadership arena or taken on a leadership role, how could that impact me?

Next Level With Values

• What does it mean if your values are absent or neglected?
• What can you do about it?

As part of this values exercise and how it ties back to burnout if you have these values and you are telling yourself they are important, but they are not present, that could be a warning sign for you. Something is amiss if we say they are important and not there. Something is off. This is part of why we want to start with values because values are part of who we are as professionals, mental health professionals, and people. If our values are not present, that could be a contributing factor. What you can do about it is another question to ask ourselves. Some of you might start to say from this exercise I remember my three values, and now I feel motivated to keep them present. I am going to do something in personal growth next quarter. I am going to figure out something in education. I am going to step up and go out of my comfort zone into a leadership role. Those might be examples that you might do to say, "This is how I am showing up and embodying my values." Then add goals specific to those values in the next three, six months, and next year to see how that might shift how you feel as a person and as a professional. Jot down a few things about what you think you can do if your values feel neglected or absent. How can you bring those back to the forefront for yourself?

What is Burnout?

Figure 2. Images showing burnout.

As we move into the second part of the equation, we have started talking about burnout. Burnout is a buzzword showing up everywhere. I said that burnout's on the rise. We have talked about 75% of the American workforce has experienced burnout symptoms. What is it? Maybe if you look at these first three images in Figure 2. You will start to get a sense of what you think burnout is. What could it be? Maybe you are writing down some of those things that are coming to mind. Is burnout a loss of focus? Are burnout, stress, and anxiety-like this middle image? Is burnout isolation being withdrawn? Is burnout about feeling overwhelmed? Many things go into the burnout experience. What if I told you there are more than 40 symptoms to keep track of for yourself and clients experiencing burnout? We are going to look at those.

Exercise #2 Burnout Symptoms

Exercise number two is about identifying the symptoms of burnout for yourself or, if you were to work with a client on this, having them identify them for themselves. Here on this list in Figure 3 are 40 symptoms of burnout.

Figure 3. Forty symptoms of burnout from www.Vitalhearts.org.

I can tell you, as a professional that has gone through burnout one and a half times in my career far, I knew about quite a handful of these, but there were still some that caught me by surprise. Let's talk about the ones that we kind of know and that have been normalized in our community. Number two, "I feel more irritable than I would like?" Short-fused might be how a client describes this to you. Maybe it is about feeling like you have no energy.

Number eight, "I have no energy to listen to my family when I get home." Maybe it is about number 21. "I do not share my work with my friends. They do not get it." Especially as mental health professionals, it is hard to feel we have to hold for confidentiality, but also that some of the things we hear are super heavy and traumatizing. We cannot open up to our friends or family about what we have done daily as mental health professionals.

Maybe you resonate with number 25. "I feel pessimistic as the result of my job." Well, there is that vicarious trauma, compassion fatigue combination that, if you are working with intense trauma or abuse, or neglect, can impact your worldview and how you see the world outside of the work you do as a professional. Some of us avoid violent movies, dramas, or TV shows that feel like work. I can tell you, as a professional myself, I do not like watching heavy content because it feels like work. I would rather have light and fluffy, funny movies, comedies, rom-com, something that feels lighter than the reality of what we do for a living.

Maybe it is number 31. "My health has declined." In my first professional burnout experience, I can admit that it took about two years to recognize I was in burnout and about a year to recover. That is disheartening for some of you to hear because a year feels like a long time to recover from burnout. Yet I went two years as a mental health professional ignoring my symptoms, being able to talk to clients about their health and wellness, but ignoring my own. I kept chalking it up to, "Oh, I am stressed. I am stressed. It is fine." I was working with a difficult population at the time. I had justified all the things.

It took my declining health to wake me up. For some of you, it might be a medical crisis or your health declining in some way for you to say, "Oh, this is not chronic stress. This is something more, and I want this to feel differently." My personal favorite on the list is number 35. "My road rage has gotten worse." Some of you might be like me and say, "Oh my gosh, I did not even realize that was connected to burnout," and yet it is. As part of that short fuse, irritability, number two can manifest as "I am angry on the road. I have a short fuse while driving or a low tolerance for other drivers." 

When I went through my first burnout recovery and started processing this number 35 with colleagues, I said, "Wow, that is eye-opening." For some of you, you might feel called out, and it is like a more playful way. As you look at this list of 40, notice what shows up for you. Which ones would you endorse? Which ones would you say, "Yep, I have experienced that"? Are there any that are missing from this list for you as you think about what it would be like to create your list of symptoms for burnout? If you have experienced it, maybe you have experienced and have healed from it, maybe you are in the midst of it right now, or even as part of burnout prevention, are these the things you are going to be looking for to make sure that you are paying attention to the warning signs?

I would love for people not to go through two years of ignoring it, like I did, to get the support and wellness they need. You are all here because you want to avoid that burnout.

Self-Reflection #3

• What’s one symptom of burnout for you?

As you reflect on this, what is one symptom you related to? What was one symptom from that list of 40 that you are like, "Yep, that is me." Even if it is not here and now, is there something in the past that would have shown up? If you find yourself stuck and not recognizing a symptom, you can always ask someone who knows you well. A loved one, a spouse, or a child. Hopefully, an adult child, we do not want to add stress to them.

Somebody who knows you, "What did I look like at that time in my life?" Sometimes they are the ones to say, "Oh, you were irritable. Oh, you ate a lot of sweets. You did not want to talk about work. You slept a lot more." Whatever it is. Sometimes our loved ones can be the ones to hold up the mirror, saying, "This is what you looked like." Burnout is not about having one symptom. If so, we would be done. As you saw, there are 40 symptoms because they all interplay with each other.

Next Level Burnout

• What does burnout look like for me?

If we were to take this to the next level, the next worksheet that I would want you to consider is the one that says, "What does burnout look like for me?" What does this look like, customized for you? Or, if you were to engage a client, how would you walk them through this worksheet together in Figure 4?

Figure 4.  Burnout worksheet (Croswaite, K., 2017). 

There is something very powerful about the visual of seeing all of your symptoms organized this way. Starting with physical, what would be some burnout symptoms for you or a client that would show up in the Physical box? What are some examples? Physically is it that they gain weight, have no energy, break out with eczema, or are losing their hair? Maybe they feel like they have a puffy face, are pale, or are moving slowly. Their limbs are very heavy. Recognizing that those are some quick examples of what might show up physically, what would you put in your box?

As we move to Emotionally, what does burnout look like for you? Is it that short fuse or irritability? Is it a loss of focus? Is it you cry much easier? I hear a lot from clients and colleagues that it shows up under the surface. Maybe you feel numb. In contrast, maybe you are not crying. Maybe you are dumb. Do not feel anything at all. Recognizing the Emotional box can also be eye-opening if you have already completed this for yourself or a client.

Intellectually, what shows up for you when you are in burnout? Are you having trouble with deadlines, again, unable to focus? Do you feel you are distracted easily and cannot retain information? Maybe you are trying to learn something new, and it is not sticking. Intellectually, noticing how you function in the workplace. Is it about having that tip-of-the-tongue phenomenon where you are like, "I can remember the thing, but I cannot articulate it"? Are you tripping over your words? Are you noticing that your brain is moving faster than your mouth, and you are feeling discombobulated? Those are some examples of what might show up in the Intellectual box.

Spiritually, now for this box, I always put the disclaimer that spirituality is not specific to religion. It might be spiritual. How you show up in the world: mindfulness, beauty, being present. Spiritually, when you are in burnout, what happens? What do you look like? Are you going through the motions? I had one client who described they were stuck on their phones. They were not noticing their environment. They did not notice the colors of the leaves changing, it was getting dark outside, or there was snow. They were focused on the phone. Spiritually, not being able to appreciate the things around you. Beauty, seeing different things, and smelling different things. How would burnout show up for you spiritually if you identify with religious practice? Are you questioning your beliefs? Are you feeling dejected? Are you feeling, you know, a different way about your religion than you normally would?

Additionally, the Work box is specific because most people, when we think about burnout, think about work. That 75% of the American workforce is thinking about work, yet burnout shows up in all different parts of our lives. That is what we saw with those 40 symptoms: they do not apply to work. They ripple out into our relationships, personal lives, and4 interests or lack thereof. I wanted to separate our work from the physical, emotional, intellectual, and spiritual because work might look very different. Your burnout shows up differently at work than at home, or at least that is my experience as someone who is through professional burnout.

At work, how do you show up? Are you now a workaholic because you are compensating? There is a running joke for mental health professionals that we would rather focus on other people's problems than our own. I say that with love and a smile because sometimes that is what keeps us going is focusing on someone else. As we are crashing and burning at home, maybe we are feeling solid at work because we are focused, and this is where our energy is going. At work, maybe your burnout is showing up as workaholism. Or are you checked out? Are you a disengaged employee or contractor? Are you fantasizing about selling your own business? Are you fantasizing about starting over or doing something completely different outside of mental health?

Those are all things I can normalize in the work that I have done with fellow clinicians. In your relationships, how does burnout show up? If we have that short fuse or are quick to cry, how does that show up in relationships? That is an example of some of the symptoms. Are we checked out? Is our tank empty because we give it all to our clients? We have nothing to give our family, loved ones, and pets when we come home. Is it about avoidance? "I do not want to talk about anything deep. I do not want to fight with you. I am exhausted." Is it about conflict because we feel that short fuse? However this relates, the hope is if you were to take this exercise to heart, you would fill it out so it is completely representative of your experience, not anyone else's.

If you decide to apply this with a client, what impact would it have to see all of those things listed in each box for them to say, "Wow, I did not realize my burnout showed up quite like this," or, "Now it feels more real." Is there motivation to do something about it? This exercise is about putting it on paper and seeing a whole picture of how burnout shows up in all the different spheres of your life.

Self-Care Strategies

Figure 5. Self-care strategies.

Now that we are aware of our burnout and have reflected on our values, self-care is the third category. For any of you who decide to see my TEDx talk, you will know that I hate the word self-care because of the pictures you see in Figure 5. Self-care has been commercialized. And for mental health professionals, many of us would say we do not do it well. We stuck at it. I say that with love and zero judgment because that is me, or it was me in my burnout journey. If you are thinking about this with clients or want to give yourself some self-compassion, identify that self-care has shifted but, for a while, looked like these things. These pictures represent some of the commercialized self-care we expect to d? Everything from meditation or yoga practice to travel, massages, manicures, and pedicures, bubble baths. Like, we have got all these stereotypes of what self-care could be.

Now, if you were a mental health professional at the beginning of the pandemic, you saw all these things go out the window quickly. It was like, "Nope, cannot do any of them. Cannot leave. Have to stay home." All of a sudden, self-care, by this definition, was not accessible. That is a problem. That is a problem for you and me. That is a problem for our clients. Self-care should not be these things. Self-care should be specific to what works for each person. Many clients we serve do not have the mental or financial resources to go on vacations, take time off of work, or have a massage. We need to get more crafty with our self-care strategies that are not the stereotypes you see here.

Exercise #3 Self-Care Wheel

Before we do that, we should probably start with the foundations of what self-care could be. Figure 4 shows the Self-Care Wheel that I love from Rachel Lane.

Figure 6. Self-Care Wheel (Lane, R., 2017).

I have used it for years and years because I think it is a powerful representation of our self-care when it comes to the traditional categories of functioning. Not massages and vacations, but here is how you show up in everyday existence. If you were to engage in this exercise, I would first encourage you to define each category for what it means to you, or if you were to do this with a client, what it means for them.

For example, in the top-right box, getting restful and enough sleep. One person's answer could be, "I get enough sleep if I get eight hours." Another person's answer could be, "If I fall asleep before 2:00 AM, that is a victory for me." Keywords "restful" and "enough" and having them measure and quantify those. What is restful and enough? Is it about not waking up five times? Is it about going to sleep quickly? Is it about a certain number of hours of sleep? have the person define that first before they jump into the exercise fully. as we work our way around the wheel, another personal favorite is what about exercise? What do clients think we are asking when we say, "Tell me about your exercise?" 

Well, for the most part, in my experience, it has been, "Oh, I must be failing that exercising because I do not go to a gym." Now, I work with clients of all different financial backgrounds. A gym is not a high priority, financially or otherwise. We want clients to challenge themselves to think about exercise from a different lens. Is it about how often they are moving around? Is it that they work a job on their feet, for example? Are they walking to the bus stop and back? Do they have a pet that they walk after work? Those are all forms of exercise that have nothing to do with the gym. That could be another way to define this category before they make assumptions about, "I am doing it well" or "I am doing it horribly." 

As we move around the circle, socializing with friends is a category. Pretty self-explanatory. What do they like to do with their friends? Do they like to play video games? Do they like to go out? Do they like to eat? Do they like to watch movies? What do they enjoy with their friends? Now, even introverts can socialize with friends. It might be less time. It is not a big part of their self-care, but it is still a part. What do they enjoy with their friends, even for a couple of hours versus a whole day? The bottom two are personal favorites for me as a mental health professional because you can have your client define this any way you want and for yourself.

Keeping a positive mindset and perspective might be all about boundaries, right? As mental health professionals, we love boundaries. What does keeping a positive mindset and perspective look like? Is it having healthy boundaries with other people? Is it about doing a gratitude practice? Is it about journaling? Is it about sharing your victories and your goals with others? Like, how do we keep that positive mindset? For many people, it will be unique to each of them, but maybe it is about gratitude and saying out loud what they have accomplished as two possibilities. In contrast, protecting your energy from negative influences still has that boundary component about who we share our energy with and our time. Especially if we are in a burnout place, we do not have a lot of energy, to begin with, let alone how are we going to give it to others or spend it on others?

Protecting your energy might be, "I am going to limit how much time I spend at that family function," or "I am going to bookend this heavier conversation with a colleague with something positive after, taking a walk or taking a nap to reset." Those kinds of things. For those that usually say, "Well, I have some pretty heavy interactions with family." We cannot necessarily restrict all of that, nor should we. Maybe it is about being intentional with what you do before and after and even how long you spend with that person so you do not feel completely zapped after the fact—using music or movies to soothe your stress. I would also add reading to this category.

If you have people who love to read, that could also be in this category. It could be read as music, reading, or movies to soothe your stress. And what does that look like? Is that something they enjoy? Is there one particular thing they like over another? Having people define that category for themselves. Moving up to eating well, another favorite 'cause what the heck is eating well? Each person's going to define this differently. One client will say eating well is remembering to eat at all during the day. Another client will be like, "I feel victorious if I have eaten breakfast." Another person might be, "I like to snack all day, and that feels good to me," versus someone who says, "I want three meals a day." 

Eating well can be defined completely uniquely to the person before they even go into how they are showing up in this arena. We want to make sure it is very clear to them how they define it before they jump in. And last but not least, engaging in humorous and fun activities feels like a repetition of socializing with friends, but as you will notice, this could be independent and separate. These could be things you do by yourself. To me, it is about, you know, watching a funny show, listening to comedy, doing something playful like dancing around your house. Does not require others. For the introverts in the room, this category might be yours. "I enjoy doing things by myself," and that is why I think Rachel Lane separated this into a different category.

We have defined all of the categories. The next step is to identify the number and numerical value we would put on each. On the worksheet you have access to, the directions say 1- completely dissatisfied and  7 -completely satisfied. Recognizing this is a snapshot in time, this wheel will look different from moment to moment, day to day, week to week, and month to month. If you were to use this with a client, it is a visual snapshot of where they are in the moment that you are talking to them or as their homework, depending on if you like homework. For yourself, if you were to do this with me at this moment, it is a visual snapshot of where you are right now.

Having a person circle the numerical value they feel fits where they are in this moment. 1, completely dissatisfied. 7, completely satisfied. Going around the wheel, circling off the numbers, with the last instruction to connect the dots. What is powerful, why I like this visual much, is the question asks us, what kind of shape did you make when you connect the dots around the wheel? It is very rare for me to see a circular shape. I usually see a starfish or some geometric shape where there are some solid numbers, like 5, 6s, and 7s, and then a couple of 2s and 3s. It looks a little more jagged. The question to ask ourselves is, if this was a wheel, how well would it roll?

For most of you, if you are a visual learner like me, that is a powerful question to ask. If I have a zig-zagged, jagged shape, and we are asking how well it would roll, it would kind of start-stop, clunk along, where there is maybe a rounded edge and then a big old chunk missing. In terms of self-care, we are not looking for perfect 7s. In 12 years of doing this, I have only seen one where it was perfect 7s, and I did not even believe them because they did not put a lot of thought into it. I could tell that this was not an exercise they had a lot of value in. For everyone else, because we see that weird shape, we can say it is about having balance.

Keyword balance. We are not looking for perfect 7s. We are looking for a well-rounded, well-balanced shape. If we have a lot of 6s and 7s on humorous activity and enough sleep but 2s and 3s on protecting negative energy and keeping a positive mindset, how do we balance that out? Those are questions to ask ourselves.

Self-Reflection #4

• Pick a category you feel you can focus on this week. What category did you pick?

As you think about your wheel, if you went ahead and decided to try this exercise and put your numbers out there, what is one category you feel you can focus on this week? What category did you pick? Coming back to our wheel, let's say you say, "Okay, I wanted to focus on socializing with friends. I was at a 3 or 4.

I would like to see that higher. My friends are important to me. I have not had a lot of time lately. I am going to pick that as my homework, my self-care homework." Maybe it changes your whole outlook on spending some time with your friends. Does it hold you accountable to say, "I need to reach out and schedule a lunch or a dinner, a walk with a friend," and see how that improves your mood and self-care? By no means are we taking all of the categories and saying, "Fix all of them right now," but you might have some intentional homework for yourself around, "I am going to pick one or two categories to improve upon and see if that changes my whole self-care strategy." 

That can be the powerful element of watching your wheel get a little bit more well-rounded from your efforts. If we were truly to take self-care to that next level, this is where I would redefine it when I said I hate the word self-care. If I could scrap the word self-care, I would. I redefine it as rest versus restoration. If people are saying, "Self-care, do self-care," we have been hearing this since grad school, "Do self-care, do self-care," but none of us knew exactly what it looked like. If we can redefine it this way, I think we can be more effective in doing and implementing it.

Next Level With Self-Care

• How do you define rest?
• How do you define restoration?

(Croswaite, K., 2021)

What do I mean when I say rest? What comes to mind for you? Rest could be everything from having nothing on your calendar to having a day off of work to unplugging from your technology and turning off your phone. For many Americans, it might be, "I am going to sit on my couch and watch a show or binge-watch a show and order takeout and relax." If that is your definition of rest, that does have value in our self-care plan. However, it is common for clients and colleagues to come back to me after a weekend of rest and still not feel great. Maybe they are saying, "I feel worse now than ever because I went from 60 miles an hour work-week to zero, and now I feel like I have been hit by a truck." 

Rest is a part of the equation, but we are missing a component: that restoration that has helped many of us through the pandemic and beyond. Yes, we want some rest in that recipe, but we also need restoration. What is restoration? When I introduce this to clients and colleagues, restoration energizes you, reinvigorates, boosts you up, and makes you feel alive again if you are feeling depleted. With that very quick definition, what would you put in your restoration for yourself? What restores you? What kinds of activities would show up here? If the rest is, "I am going to hang out and not have anything on my calendar after feeling scheduled or overscheduled all week," that is a part of it, but what will restore you to having that free space in your calendar?

Is it taking a nap? Is it dancing around your house? Is it doing something playful? Is it in nature? For some of you, it is baking. Others might be jigsaw puzzles, art, gardening, or dog walking. Each person's unique in what they will answer as restoration. For many of you, it is about starting to craft your list of things that do restore you. That is what I invite you to do with this slide define your rest and what that could look like, but then also define restoration and have some examples at the ready. When you have that next intention of, "I need to do some self-care," you have got some ideas right there that make it that much easier to do the self-care we are all told to do.

Wellness Plan

Figure 7. Wellness Plan.

Our wellness plan is our last exercise to cement all these things together. We have talked about values and how those show up and put us at either greater risk of burnout or prevent burnout if we are living in our values. We have talked about burnout symptoms. Now we have talked about self-care and what that can look like now, more than ever. The last piece is to put it all together with a wellness plan. Now, some of you have heard of wellness plans before because there is something called a Wellness Recovery Action Plan, a WRAP plan, and that is what we are modeling in this next portion of the presentation. The images in Figure 7 show a big contrast to the self-care images when we think about wellness.

Self-care, we saw meditation or yoga, vacation, and massages. What is being embodied in these pictures? Is wellness about connection? Is wellness about nature and movement? Is wellness about laughter and joy? Hopefully, it is all those things for you because that would be a nice balancing act for the self-care strategies we are discussing.

Exercise #4: WRAP

Let's look in real-time at what a WRAP plan would be. I call it a Personal Wellness Plan. It is a Wellness Recovery Action Plan, and this is one of your handouts from today's presentation in Figure 8.

Figure 8. WRAP Plan (https://brss-tacs-decision-tool.samhsa.gov/DA_files/LearnMore_Wellness_Toolbox.html).

It is similar to our burnout worksheet: boxes, nice white space for you to jot down a few things. Starting in the top-left, what does it look like when I am well? Pull in some of that information from the burnout conversation, pulling it from your awareness of yourself. Physically, what does it look like when I am well? How do I know when I am doing well emotionally, intellectually, and spiritually? Super powerful when working with clients for them to have self-awareness on this question. Do they know what it looks like when they are doing well? Maybe it is easier to start on the right-hand side with what it looks like when I am not well. Sometimes they are opposites of each other. If they start with a, "I am not well, physically I am lethargic, I am feeling heavy, my body hurts," maybe on the well side, "I feel energized, I feel like my posture is better, I am not in pain," might be the contrast.

Emotionally, what does it look like when I am not well? Again, tearfulness, short fuse, irritability, numbness, checked-out verses, in contrast, "I am present, I am engaged, I am animated." Sometimes clients are aware of their facial expressions changing from flat affect to being present again. That could be powerful to see on paper. Intellectually, that loss of focus, taking in new information, remembering deadlines, remembering important things, having someone repeat themselves versus a lost train of thought. All those kinds of examples there versus that spiritual component. Yet again, not about religion, but about spiritual showing up in the world, presence in the world. Can I notice beauty? Can I notice changes in my environment versus being stuck looking at my feet and phone? Going through the motions?

Internal warning signs are similar to some of the safety planning you have done in other training. Warning signs, internally, what shows up for you or for a client if you are doing this with a client? What shows up on the inside that tells 'em that they are not doing well? Things like restlessness, irritability, feeling like they are on pins and needles, and feeling physically off. One client described it as their muscles jumping, and they had all these muscle ticks and twitches happening, which was very distracting. Other warning signs like negative thoughts, suicidal thoughts, catastrophizing, and black-and-white thinking might be warning signs on the internal side for you or a client.

In contrast, triggers are external things. What is happening outside of you or a client that would be adding to them not feeling very well? Maybe it is a fight with a partner, a trauma anniversary, a recent event, a political component, or something that stresses them out. Maybe they are having financial hardship, or they are having a hard time at work. Maybe their relationship is rocky. Maybe their dog is sick. You know, different things would contribute to them not feeling very well at this point in their life. Again, a snapshot in time.

The next would be My Supports as we move further down the list. My Supports has a primary, secondary, and then a relationship that I want to improve or, like, have more contact with. Who are your primary supports? Would this be a spouse or partner? Would this be a nuclear family member versus extended family, or a mentor or godparent versus friends, colleagues, or coaches? Having people think about who their supporters are. This one can be a mixed bag of emotions for folks, especially if they feel they have avoided or withdrawn from people as part of their burnout. Be very careful about how you tread on this topic because some people will get a little bit heavier, realizing that they have let some of their relationships go or have ghosted as part of their burnout, holding some compassion for that.

When Things Are Breaking Down is my favorite box. When things are breaking down as in, how do they know when things are spiraling out of control? We can have "I am not looking well" warning signs and triggers, but when does it get to that next level where it is, "Ew, I need some support, or I need something to change, or this is going to spiral out, and it is not going to be good." Maybe now they are picking fights, maybe they are self-sabotaging, maybe they are using substances or other negative coping skills. Maybe they are trying to attend to their grief through compulsive shopping or things of that nature. Noticing self-awareness, what would they put in this box for that reason?

As people are crafting these boxes, there are two more below this: What Do I Need from Others, a very powerful box to ask or to fill out, I should say. I am asking it of you. Hopefully, you are filling it out. What do I need from others? Do I need them to leave me alone? Do I need a hug? Do I need support? Do I need a distraction? Do I want someone to, you know, help me tackle laundry? What will help the person feel like they are returning to a place of wellness? And that is a vulnerable question of, "What do I need from others?" I recognize that can change from moment to moment, "I need a distraction" versus "I want to be left alone" are the two contrasts I hear—holding space for all of that if you do this with a client or for yourself.

Self-Reflection #5

• What’s one idea in your plan of action for when things are breaking down?

As you have crafted your wellness plan, what is one idea in your plan of action for when things are breaking down? You know, is there something you want to do to stop the spiral? Is it reaching out for support? Is it talking to a friend? Is it talking to a colleague? Even someone who has been through this. Who has been through their burnout? Can you understand how tricky it can be? Because it is hard to recover from something when you are still living in it. Is there a step you want to take? Taking some time off, if you have that ability?

Does that cause you stress and anxiety to think about taking time off? is it more about being intentional with the time off on your weekends or your scheduled days off from work? Thinking about what is that one idea in your plan of action for when things are breaking down and how we implement that would be that next step. Recognizing that this wellness plan can be as much, it can be as helpful or as unhelpful depending on how much you put into it. How much energy do you put into it? To take that to the next level, I have some suggestions. It does not become another piece of paper that you have written some stuff on and forget about, because, I say, again, that with no judgment because that happens.

Next Level With Wellness Plan

• Accountability Buddy
• Feedback from Others
• Month Check-in
• Compassion Satisfaction and Fatigue Test

https://www.isu.edu/bhstamm

Here are some ideas to have the wellness plans serve you the best possible. First of which is an accountability buddy. When I first learned how to do a wellness plan, they had to sit alongside someone and had to share all of those components in each of those boxes, not from a place of vulnerability but that someone could, like, ask clarifying questions, recognize, "Okay, is there an action step that we have forgotten?" "You said this is important, but it is not in this box." That can be empowering to have somebody sit alongside you but also check-in and ensure the things are represented. In those action steps, the accountability buddy can say, "Hey, did you take that time off?

Did you do some rest? Did you do a restoration activity? How did that go for you?" Many of you are familiar with accountability for lots of different therapeutic exercises. This is another area where that could apply. it is about getting feedback from others. If you find yourself trying to fill out your wellness plan and you have a mental block or writer's block in trying to put something on the sheet, who can you ask that can help you fill out and flush out what you look like when you are well, unwell, what the triggers and warning signs are? Who knows you the best? Who can help you with this? Now, the biggest task of vulnerability is asking someone who knows you well to help fill in the blanks if you feel like you cannot.

Sometimes what they have to say is somewhat painful, "Oh yeah, that is true." "Ouch." Feedback from others matters. Sometimes it is about flushing out the areas you cannot think of or addressing that writer's block if you have it, but it can be a very powerful tool in connecting with people around how you are doing. I use them in therapy a lot, the mirror image. Holding up a mirror and showing us how we are showing up to others and having a trusted person do that is powerful. I encourage .you to identify someone in your life who can hold up that mirror and say, "Hey, here is how you are showing up."

Here is how you are looking right now," and give you a chance to adjust and reflect. The monthly check-in is like the accountability buddy, but more, it could be a monthly check-in with yourself. What would it be like if you crafted it, handwrote your wellness plan, or typed it up? Putting a reminder in your phone to revisit it in a month and see how it is applying? Is it a gentle reminder to keep doing a couple of things? Is it, "Oh my gosh, I did none of those things?" Is it, "Oh, I forgot about this completely, let's try some goals for next month." By doing a monthly check-in, it stays fresh.

It does not be a one-and-done. You can revisit it, revamp it, rewrite it, whatever it takes to feel like the wellness plan is serving you or your client if that is the person you are doing this with. Last but not least is the Compassion Satisfaction and Fatigue Test. Now, this is a public document, that is. I believe 63 questions long. It is quite robust that way, but it is a document that people can administer to check in on satisfaction versus fatigue when it comes to compassion. A powerful weighing out of both compassion satisfaction and fatigue. I enjoy doing this with teams to ensure that my team is healthy. It gives them a chance to give me, you know, kind of an almost anonymous way of saying, "I am not doing well," or, "Here is where I am feeling good about my client work," "Here is where I am struggling," but also gives them that visual.

It can be a mile marker of, you know, here we are, and then six months from now, how is that looking? Did your satisfaction come down? Did your fatigue go up? Is there vicarious trauma we need to adjust and navigate in that way? Great for teams, but it also can be another touchpoint for you as a clinician to gauge your functioning. Where are you in satisfaction versus fatigue? Of course, it has a category of burnout as well. That document is also part of your handouts for this presentation to grab and utilize how you see fit. Again, 63-plus questions give us a sense of some powerful things we can ask ourselves but also measure that satisfaction-fatigue and burnout combination.

Other questions that come up before we do our wrap-up. The big one I started to talk about is how long it takes to recover from burnout. In most people, at minimum, it is going to take a year because it is one of those things that requires intentionality, like flossing, right? You gotta create a habit out of it. They say any good habit takes at least 30 days to cement. And if we are talking about that and then having to build off of different habits to get to a place where you do not feel like you are in burnout any longer, it is pretty easy to see how that could take a year or longer for us to do.

It does not mean you have to do it on your own. For that reason, you can have the support of colleagues, friends, supervisors, coworkers, consultants, and coaches to have someone hold you accountable and help you keep slowly chipping away at that burnout and getting back to a place of wellness. That is one of the biggest questions. Another question that I get a lot is, is there anyone who is not at risk of burnout? I do not think that happens. I do not think burnout discriminates. I think burnout is a human experience of being overworked and out of balance when it comes to work and life. I know work-life balance is another buzzword, and I want to introduce you to another concept: flow.

Instead of work-life balance, now we are talking about work-life flow. And some of you might like that terminology better because balancing implies that they have to be equal, right, that work has to be an equal amount of time to home life. For many of us who identify as entrepreneurs and mental health professionals, that might not be possible. Maybe it is more about permission, "I am going to work hard for six weeks and then take a week off," or "I am going to be in the flow because I am going to have this strong flow of working with clients for a couple of weeks and then have a flow of taking some more downtime." "Or going into the holiday season where I have fewer clients, or summer where I have less to do," and giving yourself permission to go with the ebb and flow.

Some of you might like that terminology better: work-life flow instead of balance. Other questions that come up. What is another one? What prevents burnout from happening? That is a huge one. Probably not a one-and-done situation, but a couple of things help prevent burnout from being such a high risk for folks, including us as mental health professionals. The boundary is a big part of it, but in any workplace, there are a couple of other things to name, one of which is feeling like you have autonomy. Some of the research that is come out is saying if you feel like you have a say, if you feel like you are being appreciated, if you feel like you are valued in the workplace. These three things would prevent burnout because now we feel emotionally invested in our work and appreciated for our work.

As a mental health professional, I do not think that it is a foreign concept to be like, "Hey, everyone wants to be appreciated. Everyone wants to feel valued."  We are providing a safe space for clients to echo that, and now we are looking at it for ourselves in our burnout recovery and prevention. If you are desperately trying to prevent burnout as part of your professional journey, you know, making sure that you are in a workplace that respects you, values you, provides autonomy and allows you to grow. These are the points of contact that people are noticing that prevent burnout from happening. Hopefully, that resonates, and it does not make completely nonsensical sense because we all want those things as humans.

Those things come up. Let's see, what else can I tell you that people have asked a lot about? Oh, here is a good one. in addition to those 40 symptoms of burnout, there was one significant thing that happened in 2020 that was another sign of burnout that we had not seen before: cracked teeth. According to US American dentists, we saw more cracked teeth in 2020 than we would see six years prior. Wow, more cracked teeth in 2020 than we would see in all six years prior. Well, that tells you we are under immense stress. It was the beginning of the pandemic. That was a factor. It was people working from home. Another factor was a lot of the stress and the poor work-life balance or poor work-life flow.

That all got tossed up in the air and disrupted as part of that pandemic. Not only are we looking at road rage and comfort in sweets and irritability and avoidance and all these things we have named, but we are also now looking at cracked teeth as a sign or symptom of burnout. That is pretty wild, too. With all this being said, if you are looking for additional strategies for your burnout recovery, we have looked at five today, right, four in real time, plus that Compassion Satisfaction and Fatigue Test. There are also some other great trainings out there. One I like to reference today would be the VitalHearts training. It is compassion fatigue training, also called secondary trauma training.

That is a two-day intensive where people get a look at their burnout symptoms but also start to recover from those symptoms. That was part of my burnout recovery journey. I did mention I have been in burnout 1.5 times. I playfully say one and a half because I started to see some of those same warning signs we talked about today, and I had to change to not go back into burnout a second time. I want to normalize that for everyone.

Wrap Up

Burnout is a challenge. It is an ongoing thing we must monitor, like self-care. As we look at the next steps, do not forget to floss is the analogy again. Creating habits. Habits take 30 days. Implement some of these strategies for clients, if not for yourself, because burnout does not discriminate. Anyone who is in the workplace or going through any amount of significant stress has the risk of burnout. That is something to think about. Noticing how we can make a difference and make burnout not part of the mental health experience as much as possible.

Question and Answer

That is interesting that you talked about cracked teeth. About 2021, when we were still having COVID issues, I started having a lot of teeth problems. I had to have wisdom teeth removed, and they said I was grinding my teeth. I did not have any issues with my teeth before that.

I appreciate you sharing that. I think people were more likely to say they were grinding teeth or would have tension headaches because they were clenching their jaw much with the stress of everything we were going through. If it was not cracked teeth, it was one of those other two, of tension headaches or grinding their teeth down to nubs. Mouthguards became popular again, and we were all trying to navigate it in a way that the dentists were saying, "What is happening?"

My dentist said, "You are grinding your teeth." I said, "Well, I have never grinded my teeth. I have never done that before, but now I notice it." If I have any stress or tension, I will feel it is very tense back here. That is a very interesting thing that they found in that study. It reminds me of one of my favorite activities, which is very simple, in the mental health sphere that I am sure participants here would appreciate if they are not already doing it, which is a lot of times when we are trying to drop into a space, whether it is work or being with a partner, getting ready for sleep, or winding down. It is doing a quick body scan, putting our feet flat on the floor, noticing our feet, and slowly coming up the body. Every time I get people to their chest, they recognize, "Oh, I am not breathing very deeply," and then they will start to breathe better. We get to the jaw, and I say, "Soften our jaw." They say, "Oh my gosh, I was clenching my teeth, and I had no idea I was clenching my teeth until you said, soften it." That can be something that can be a gentle reminder for each of us at night or whenever to let's do a quick body scan. Let it all loosen up and soften the jaw because most of us do not even recognize that we are carrying our jaw that way. I want to normalize that.

One of the first things they say when you are in a yoga session is, "Everyone, open your mouth and let your mouth hang open," releasing that tension. I always thought that was strange until I realized why they were doing that. Another thing I have been doing to help me sleep is I love lavender. It relaxes me. I put that on as hand lotion when I go to bed. I am a side sleeper and have my hands up by my face. I think it helps me to sleep.

Are there other tips or tools that you have similar to that engage the senses?

I think the sleep piece was a huge disruption and continues to be a disruption in burnout, where people are either sleeping too much, getting poor sleep, or not sleeping enough. I love lavender, essential oils, and things like that. It is all part of what we call sleep hygiene. What is your routine to get ready for bed to tell your body it is time to wind down? Everything from 20 minutes off your electronics, which is hard to do, to lavender or brushing your teeth or any of the things that would be a routine. To your question, one of my favorite activities is activating all five senses and figuring out a coping kit with all five senses accounted for.

I usually start with what you like to look at that brings you joy or comfort or calms you down. It might be pictures of family, pets, or nature that you could pull up on your phone when you are stressed. What are smells? That could be lavender or a familiar cooking smell, grass. Sometimes people like nature smells, like, fresh rain. Having them walk through all five senses can create a coping kit where they can start compiling those things to have them handy. If it is nature, it might be, "I need to get outside and take a walk in green grass." "I need to pull up a picture of my mom." Make it accessible.

My favorites are the sense of taste because those are the most intentional. Do you like mint and have that on your desk? Can you have like something spicy if you like spicy? Do you chew gum? Any of the things that people are not thinking about can have a significant impact on them feeling more relaxed quickly.

Did you find once you incorporated some of the sleeping and things in your journey, you felt better later on? For example, going back to work, did that help relieve some of that pressure?

For me, it was the boundary of not working 24/7. I had to set a regular bedtime and get up even though I did not feel like getting up. I know it is hard for many of us when we are feeling depleted, but I learned very quickly that I needed a certain number of hours of sleep to feel functional. I would not even say happy but functional. I had to start there. Then getting up every day, even on weekends, I had to get up at the same time. I would not do that whole, "I want to catch up on all my sleep and sleep until noon," but that did not work for me, and for most of my clients, it does not either because it is disruptive.

If you get up at 6:00 on a weekday, you are getting up at 6:00 on the weekend. That does not mean you do not get a chance to have a nap. By all means, have a nap. Letting the body have that rhythm, "Oh, this is when we wake up, this when we go to bed," has been helpful for mood and burnout.

References

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Johnson, J., Hall, L.H., Berzins, K., Hons, J.B., Melling, K., & Thompson, C. (2018). Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. International Journal of Mental Health Nursing, 27(1), 20-32.

Northwood, K., Siskind, D., Suetani, S., & McArdle, P. (2021). An assessment of psychological distress and professional burnout in mental health professionals in Australia during the COVID-19 pandemic. Australasian Psychiatry, 29(6), 628-634. doi:10.1177/10398562211038906

O’Connor, K., Neff, D.M., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53. 

Posluns, K., & Gall, T.L. (2020). Dear mental health practitioners, take care of yourselves: A literature review on self-care. Int J Adv Couns, 42(1), 1-20. doi: 10.1007/s10447-019-09382-w. Epub 2019 May 23. PMID: 32435076; PMCID: PMC7223989.

Rivera-Kloeppel, B., & Mendenhall, T. (2021). Examining the relationship between self-care and compassion fatigue in mental health professionals: A critical review. Traumatology. Advance online publication. https://doi.org/10.1037/trm0000362

Seward, M.W., Marso, C.C., Soled, D.R., & Briggs, L.G.. (2020). Medicine in motion: Addressing physician burnout through fitness, philanthropy, and interdisciplinary community building. Am J Lifestyle Med., 16(4), 462-468. doi: 10.1177/1559827620983782. PMID: 35860365; PMCID: PMC9290178.

Tanios, M., Haberman, D., Bouchard, J., Motherwell, M., & Patel, J. (2021). Analyses of burn-out among medical professionals and suggested solutions—a narrative review. Journal Of Hospital Management And Health Policy, 6. doi:10.21037/jhmhp-20-153