Self-care and well-being in mental health professionals: the mediating effects of self-awareness and mindfulness.
Because mental health professionals are susceptible to impairment and burnout that may negatively affect clinical work, it is ethically imperative that they engage in self-care. Previous research has found direct effects of self-care on self-awareness and well-being (e.g., Coster & Schwebel, 1997). Likewise, mindfulness has been found to positively affect well-being (Brown & Ryan, 2003). However, no studies currently available demonstrate a link between self-awareness and well-being. Mindfulness may be the link needed to support this association. A survey of mental health professionals (N = 148) revealed that mindfulness is a significant mediator between self-care and well-being. Consequently, mental health professionals are encouraged to explore their involvement in and beliefs about self-care practices.
According to the core ethical principles of counseling, counselors have a responsibility to do no harm, benefit others, and pursue excellence in their profession (American Counseling Association [ACA], 2005; American Mental Health Counselors Association, 2010). Mental health professionals are susceptible to impairment in their professional lives that can undermine their therapeutic efficacy (Coster & Schwebel, 1997). Coster and Schwebel find that mental health professionals are vulnerable to, e.g., vicarious trauma, substance abuse, relational difficulties, and depression. Therefore, to adhere to their ethical principles, it is important that counselors engage in self-care (e.g., exercise) to decrease the possibility of impairment and enhance their well-being.
The present study explored the link between self-care by mental health professionals and their general well-being. Previous research has found direct effects of self-care on well-being (e.g., Coster & Schwebel, 1997) and self-awareness (e.g., Mackey & Mackey, 1994); however, no studies demonstrate a link between self-awareness and well-being. This omission is interesting considering that mindfulness, which has been associated with self-awareness, has been shown to have a direct effect on well-being (e.g., Brown & Ryan, 2003). This study therefore examined the direct effect of self-care on self-awareness and mindfulness and how these associations affect the well-being of mental health professionals.
What Is Self-care?
The literature reveals few attempts at an operational definition of self-care, and there is minimal agreement among definitions. For example, Pincus (2006) defined self-care vaguely as something "one does to improve [the] sense of subjective well-being. How one obtains positive rather than negative life outcomes" (p. 1). Other researchers have defined self-care by describing activities believed to constitute self-care. Carrol, Gilroy, and Murra (1999) classify self-care as including "intrapersonal work, interpersonal support, professional development and support, and physical/recreational activities" (p. 135). With these definitions in mind and after a thorough literature review, some general themes in self-care have been identified. Researchers have explored physical (Mahoney, 1997), psychological (Norcross, 2000), spiritual (Valente & Marotta, 2005), and support (Guy, 2000) components of self-care.
Physical. The physical component of self-care has been loosely defined as incorporating physical activity (Carroll et al., 1999), which in this context is characterized by bodily movement that results in the utilization of energy, which can occur through exercise, sports, household activities, and other daily functioning (Henderson & Ainsworth, 2001). The intensity of physical activity and the amount of time spent on it can vary dramatically, but recommendations from the U.S. Department of Health and Human Services and the U.S. Department of Agriculture (2005) suggest at least 30 minutes of physical activity for most days throughout the week is necessary to receive benefits
Although there seem to be many specific advantages of physical activity (Dishman, 2003), it also appears to have a general wellness benefit. It has been shown to decrease symptoms of anxiety and depression (Callaghan, 2004; Dishman). Further, Lustyk, Widman, Paschane, and Olson (2004) found that an increase in the volume and frequency of exercise increased the health component of quality of life. For instance, physical activity has been shown to increase women's satisfaction with their body functioning and their ability to cope with daily stress (Anderson, King, Stewart, Camacho, & Rejeski, 2005). Clearly, physical activity promotes a general sense of well-being.
Psychological. Psychological self-care refers to seeking one's own personal counseling (Coster & Schwebel, 1997; O'Connor, 2001). Personal counseling can be defined as psychological treatment for any type of distress or impairment (Norcross, 2005). Patterson (1966) states that counseling is a process "involving a special kind of relationship between a person who asks for help with a psychological problem ... and a person who is trained to provide that help" (p. 1). Because counselors spend a significant amount of time providing services to others, it is suggested that they themselves seek the benefits of counseling.
Among the benefits found through participation in personal counseling is alleviation of symptoms of distress and impairment (Macran, Stiles, & Smith, 1999). Through qualitative interviews with therapists, researchers have also identified other personal and professional benefits (Mackey & Mackey, 1994; Macran et al.). Personal counseling supports personal development by allowing one both to understand how to care for oneself and to develop an awareness of one's boundaries and limitations (Mackey & Mackey; Macran et al.,). Professional development, which is understood as building awareness of skills that can benefit one's career, has also been demonstrated to be a result of personal counseling. Because empathy requires understanding of another person, personal counseling has been shown to enhance counselors' empathic skills (Mackey & Mackey; Macran et al.). Given the personal and professional development that results, it appears that becoming aware of oneself is a significant advantage of personal counseling (Coster & Schwebel, 1997; Mackey & Mackey; Macran et al.; Norcross, 2005).
Spiritual The spiritual component of self-care also must be defined loosely, given how broadly its meaning can be interpreted. Spirituality can be generally described as a sense of the purpose and meaning of life and the connection one makes with this understanding (Estanek, 2006; Hage, 2006; Perrone, Webb, Wright, Jackson, & Ksiazak, 2006; Saucier & Skrzypinksa, 2006). This definition is vague enough to ensure that all beliefs of spirituality, including religion, are addressed. Behaviors sometimes considered spiritual, such as meditation, may also be included (Schure, Christopher, & Christopher, 2008).
Boero et al. (2005) investigated the spiritual/religious beliefs and quality of life of health workers. They found that spirituality plays a significant, positive role in their quality of life. Physical well-being, such as health, was also found to be significantly, positively influenced by spirituality (Boero et al.).
Mental health has been shown to be related to spirituality (Wong, Rew, & Slaikeu, 2006). It was found that greater spirituality reported by adolescents was associated with more positive mental health (Wong et al.). In another study using qualitative interviews, helping professionals discussed their spirituality and its benefits to them. It was reported to promote not only quality of life but also a sense of self-awareness (Hamilton & Jackson, 1998). Hamilton and Jackson suggest that self-awareness is central to developing and maintaining spirituality; therefore, it might be supposed that spirituality is important for the development and continued progression of self-awareness.
Support. The support component of self-care includes the relationships and interactions that develop from both professional and personal support systems. Professional support is defined as consultation and supervision from peers, colleagues, and supervisors and the continuation of professional education (Coster & Schwebel, 1997; O'Connor, 2001; Stevanovic & Rupert, 2004). Personal support is defined as relationships with spouse, companion, friends, and other family members (Coster & Schwebel; Stevanovic & Rupert).
Like personal therapy, support from others can benefit personal and professional development. Koocher and Keith-Spiegel (1998) suggest that mental health professionals should participate in routine professional communications with colleagues to reduce the possibility of burnout. Through consultation and supervision, it is possible to recognize and understand oversights and errors (Koocher & Keith-Speigel; O'Connor, 2001). Also, professional support can help guide a counselor through ethical and other clinical difficulties with cases (Coster & Schwebel, 1997). Mental health professionals surveyed indicated that professional support was the main reason for their well-being because it gave them input into various situations (Coster & Schwebel). Because professional development can occur through professional support as well as personal counseling, self-awareness may also develop from such support systems.
Stevanovic and Rupert (2004) surveyed licensed psychologists about their career satisfactions and found that it is important not to use personal support for professional stressors because personal support provides different benefits. Specifically, it satisfies the common need to belong because it establishes relationships outside the professional world. It therefore provides a healthy balance in that mental health professionals will experience their lives through both career and outside of work (Coster & Schwebel, 1997; Stevanovic & Rupert). This balance can help prevent or alleviate symptoms of burnout and mental exhaustion, or becoming a workaholic. It has been suggested that personal support enhances psychological well-being (life satisfaction and mood) and physical health subjectively and objectively (Walen & Lachman, 2000).
What Is Self-awareness?
A comprehensive literature review reveals minimal discussion of the construct of self-awareness, making defining it difficult. Additionally, most of the research that has examined self-awareness is outdated. Brown and Ryan (2003) suggest that it is simply "knowledge about the self" (p. 823). Others suggest that self-awareness is awareness or knowledge of one's thoughts, emotions, and behaviors and can be considered a state; therefore, it can be situational (Fenigstein, Scheier, & Buss, 1975). It is believed to be similar to or synonymous with other constructs, such as self-consciousness (Fenigstein et al.; Webb, Marsh, Schneiderman, & Davis, 1989) and insight (Grant, Franklin, & Langford, 2002; Roback, 1974). Because this study is exploring self-care and its benefits, which have been shown at times to be self-awareness, it is important to emphasize distinguishing self-awareness as a state. The outcome of a behavior usually tends to be a state; therefore, self-awareness may be a possible outcome of self-care.
What Is Mindfulness?
Once again, definition is a daunting task. Mindfulness has only recently been introduced to Westernized culture and there is still uncertainty about its exact definition. Researchers have a consensus understanding that it is maintaining awareness of and attention on one's surroundings; however, several models have been proposed for a more precise definition (see Bishop et al., 2004; Shapiro, Carlson, Astin, & Freedman, 2006; Sternberg, 2000). It has been suggested that the practice of mindfulness may facilitate insight, which can be understood as awareness of oneself and one's motives (Rosenzweig, Reibel, Greeson, & Brainard, 2003; Schmidt, 2004). Because insight and self-awareness have been described similarly, any connection between self-awareness and mindfulness should be explored.
Despite the suggested similarities between self-awareness and mindfulness, some researchers have begun to identify subtle differences. Brown and Ryan (2003) believe self-awareness to be "knowledge about the self" (p. 823), whereas mindfulness can be understood as knowledge and awareness of one's experience in the present moment (Byrne, 2007; Hirst, 2003). More specifically, Brown and Ryan propose that self-awareness is an internal awareness of one's cognitions and emotions, and mindfulness is both internal and external, being awareness of both one's cognitions and emotions and the surrounding environment.
Mindfulness has been used as an intervention for physical ailments in the form of structured mindfulness meditation instruction, known as mindfulness-based stress reduction (MBSR; Bishop, 2002). Through this meditation, the patient begins to develop an understanding of the self and ultimately an ability to regulate the self (Bishop). The technique teaches people to notice, accept, and regulate their emotions and thoughts (Bishop). MBSR has been used successfully to reduce stress (Rosenzweig et al., 2003) and relieve medical illness (Bishop; Kabat-Zinn et al., 1998), psychological distress (Williams, Teasdale, Segal, & Soulsby, 2000), and physical and emotional pain (Roth, 1997).
Purpose and Hypotheses
Research has thus established that mindfulness has a strong link with self-awareness and well-being (Brown & Ryan, 2003), and that self-care has a direct effect on self-awareness (Hamilton & Jackson, 1998) and well-being (Lustyk et al., 2004). However, it has not clearly delineated the direct link between self-awareness and well-being. Although it appears that self-care leads to well-being (Coster & Schwebel, 1997), it has yet to be determined if self-awareness mediates the relationship between self-care and well-being. If mindfulness and self-awareness are associated, and mindfulness leads to well-being, it would seem logical that there would be a chain linking self-care to self-awareness to well-being. This study explored such links by examining self-care practices, self-awareness, mindfulness, and well-being in mental health professionals.
The following hypotheses were examined:
Hypothesis 1: A significant, positive correlation between self-awareness and mindfulness will be found.
Hypothesis 2: The path from self-care to mindfulness to well-being will be significantly stronger than the direct path from self-care to well-being.
Hypothesis 3: The path from self-care to self-awareness to well-being will be significantly stronger than the direct path from self-care to well-being.
The study surveyed 148 mental health professionals holding a bachelor's degree or higher and practicing in the northeastern United States. According to Cohen (1992), based on the number of variables used a minimum of 108 participants is required to achieve power of .80 with an alpha of .01 and a medium effect size (r = .30). The participants were 77.1% women; the average age was 42.38 years (SD = 14.88); and 94.3% were White, 2.1% Asian American, 2.1% Latino/Latina, 0.7% African American, and 0.7% Native American. In terms of educational level, the participants were somewhat evenly distributed (30.6% bachelor's, 41.7% master's, 0.7% educational specialist/ABD, 26.4% doctorate, and 0.7% other). Their specialties were in social work (43.3%), counseling psychology (24.8%), clinical psychology (23.4%), other (7.1%), and general psychology (1.4%). Participants reported that they currently provide mental health services, defined as seeing clients for assessment, therapy, and psychological testing in a variety of settings; some respondents worked in multiple settings, including community mental health center (15.5%), inpatient hospital (5.4%), partial hospitalization program (8.1%), practicum/internship (12.8%), private practice (40.5%), Veterans Affairs clinic (0.7%), nonprofit organization (2.0%), children's welfare center (4.7%), university counseling center (9.5%), and other mental health setting (8.8%). Average years in practice was 13.8 years (range = 0 - 40).
Self-care. Participants were given a broad definition of self-care ("Self-care refers to any activity that one does to feel good about oneself. It can be categorized into four groups which include: physical, psychological, spiritual, and support") and definitions for the four components. They were asked to indicate how often they are involved in such behaviors based on a 7-point Likert-type scale ranging from "One or more times daily" (0) to "Never" (6). There were four questions, one for each aspect of self-care. For example, one item asked participants to identify how often they engaged in physical activities (exercise, sports, household activities, etc.). Since each question was developed to assess a component of self-care that is independent of the others, inter-item reliability could not be assessed. Items were reverse-scored to produce final scores of zero to 24. Higher scores indicate greater propensity for self-care.
Participants were also asked to indicate their views of the importance of each self-care component. They were again provided with a broad definition of self-care and the definitions of its four components. They were asked to indicate the extent to which they agreed with each of four statements pertaining to the importance of self-care activities, ranging from "Disagree Strongly" (0) to "Agree Strongly" (6). The possible final range of scores was zero to 24, with higher scores indicating greater agreement with the importance of self-care. Again, reliability could not be assessed for this measure.
Self-awareness. The Self-Reflection and Insight Scale (SRIS; Grant et al., 2002) has two subscales, self-reflection and insight. Grant and colleagues defined self-reflection (p. 821) as "the inspection and evaluation of one's thoughts, feelings, and behavior" and insight as "the clarity of understanding one's thoughts, feelings, and behavior." The self-reflection subscale can be further divided into the need for self-reflection and engagement in self-reflection, which have been shown to be subcomponents but are not separated out from the main self-reflection subscale (Grant et al.). The SRIS consists of 20 self-report items, to be rated on a 6-point Likert-type scale ranging from (1) "Strongly Disagree" to (6) "Agree Strongly." Eight of the items are to be reverse-scored. Possible scores range from 20 to 120, with higher scores indicating more self-awareness. Grant et al. report that SILLS has high internal consistency, with Cronbach's alphas of .91 (self-reflection subscale) and .87 (insight subscale). The SRIS has also been shown to have good seven-week test-retest reliability with alphas of .77 (self-reflection subscale) and .78 (insight subscale). Grant et al. found the SRIS to demonstrate good convergent and discriminant validity in that both subscales were not related to depression; the insight subscale was not correlated with anxiety, alexithymia, or stress; and the insight subscale was positively related to self-regulation and cognitive flexibility. Cronbach's alphas for the current sample were .78 (self-reflection) and .94 (insight).
Mindfulness. The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) was utilized in the present study to assess individuals' levels of mindfulness. The MAAS is a 15-item self-report measure scored on a 6-point Likert-type scale, ranging from (1) "Almost Always" to (6) "Almost Never." Possible scores range from one to six, with higher scores indicating greater propensity to be mindful. Reliability was good, with alphas ranging from .82 to .87. During a test-retest analysis (Brown & Ryan), the measure did not produce significantly different scores between Time 1 and Time 2, again indicating reliability. Based on two different confirmatory factor analyses utilizing student and general adult samples, the MAAS was found to measure a single factor. Good convergent validity has been demonstrated in that this measure was found to correlate with emotional intelligence, openness to experience, and wellbeing (Brown & Ryan). Discriminant validity was shown by a low correlation between the MAAS and self-examination, self-monitoring, and neuroticism (Brown & Ryan). Cronbach's alpha for the current sample was .89.
Well-being. This study used the Schwartz Outcomes Scale-10 (SOS-10; Blais et al., 1999) to evaluate participants' well-being. It consists of 10 self-report items assessing psychological health that are rated on a 7-point Likert-type scale ranging from (0) "Never" to (6) "All of the time or nearly all of the time." Possible scores range from zero to 60, with higher scores indicating greater psychological health. Blais and colleagues report that the SOS-10 has high internal consistency, with Cronbach's alpha >.90 over three samples. It has also been shown to have good test-retest reliability (r = .87) across a one-week study with a nonpatient population (Blais et al.). Further, there were no floor or ceiling effects found among patient or nonpatient populations. The SOS-10 was found to have high convergent validity in that it had a significant positive correlation with positive affect, sense of coherence, self-esteem, and general life satisfaction (Blais et al.). It also was found to have high discriminate validity, as demonstrated by its significant negative correlation with negative affect, hopelessness, fatigue, and psychiatric symptoms (Blais et al.). Cronbach's alpha for the current sample was .88.
Demographics. The questionnaire asked about age, gender, race/ethnicity, educational degree, field of study, and professional practices.
Two methods were used to mail 415 survey packets, including a self-addressed, postage-paid envelope. First, those identified as mental health professionals under the "Counseling Services" and "Psychologists" sections of the phonebook in northeastern Pennsylvania were contacted. Second, counseling and clinical psychology graduate students who were actively providing mental health services were solicited through personal contact with training directors. Reminder postcards were mailed one week after the surveys. Completion of the survey packet constituted agreement to participate. The return rate was 35.7%--148 surveys. The order of the questionnaires was counterbalanced to decrease potential response bias; but the questionnaire on self-care importance was always last so those responses would not influence responses to the other measures.
Before analysis the data were screened using Mahalanobis distance to assess for outliers. This analysis identified three multivariate outliers, which were removed from the data.
The descriptive statistics for each measure are found in Table 1. Bivariate correlations were conducted on all measures (see Table 1). Self-care frequency is significantly, positively correlated with self-care importance (r = 0.34, p < .001) and well-being (r = 0.228, p = .008). Self-awareness was also positively correlated with self-care importance (r = 0.325, p < .001), well-being (r = 0.174, p = .045), and mindfulness (r = 0.293, p < .001). The connection between self-awareness and mindfulness supports the hypothesis that these two constructs would be significantly correlated. Additionally, mindfulness (r = 0.179, p = .035) and well-being (r = 0.208, p = .014) were found to be positively correlated with self-care importance, though the associations were weaker. Lastly, mindfulness was found to be positively, strongly correlated with well-being (r = 0.541, p < .001).
According to Baron and Kenny (1986), a mediational analysis is used to assess the indirect effects of one variable between an independent and an outcome variable. This model demonstrates that a relationship may exist between an independent and an outcome variable, while an additional variable (a mediator) may be significantly correlated with both. This mediator variable may account for a significant portion of the correlation between the independent and the outcome variables. The mediator, which explains the "how or why" of a relationship, may be described as an "internal psychological" variable that accounts for the relationship between two "external physical" constructs or experiences (Baron & Kenny, p. 1176). An evaluation of the indirect effects that exist between the direct effects of the independent and outcome variables may weaken or eliminate these direct effects.
Multiple conditions must be met to conduct the mediational analysis proposed by Baron and Kenny (1986). A series of simple and multiple regressions is conducted to determine if these are satisfied. The first condition that must be met is the presence of a significant relationship between the independent and the outcome variable. There also needs to be a significant relationship between the independent and the mediating variable. Next, it is essential that there be a significant relationship between the mediator and the outcome variable. Lastly, the significant relationship between the independent and the outcome variable must diminish when the effects of a mediating variable are held constant. Baron and Kenny reasoned that a "perfect mediation" is present when there is no longer a relationship between the independent and the outcome variable when the mediating variable is held constant (p. 1177).
Self-care Importance, Mindfulness, and Well-being. A mediational analysis was conducted to assess the indirect effects of self-care on well-being. In the first step, it was found that self-care importance was significantly, positively correlated with well-being (r = .208, p = .014). In the second, it was found that mindfulness was significantly, positively correlated with self-care importance (r =. 179, p = .035). In the third, mindfulness significantly affected well-being when self-care importance was controlled for ([R.sup.2] = .292, F[1,137] = 56.594, p < .001, Beta = .520, p <.001). Finally, it was found that self-care importance no longer accounted for a significant amount of the variance of well-being after the variance for mindfulness was controlled ([R.sup.2] = .013, F[1, 136] = 2.496, p = .116).
A Sobel test was conducted to statistically assess the significance of the indirect effect of the self-care importance [right arrow] mindfulness [right arrow] well-being relationship. The results were significant, z = 2.09, p = .036, which supports the indirect effect of mindfulness as a mediator between self-care importance and wellbeing (see Table 2 and Figure 1). This indicates that mindfulness is a significant mediator of self-care importance and well-being in mental health professionals, a finding that supports the hypothesis that the direct effects between self-care and well-being are mediated by mindfulness.
[FIGURE 1 OMITTED]
Self-care Frequency, Mindfulness, and Well-being. To assess whether mindfulness is a significant mediator of the relationship between self-care and wellbeing in mental health professionals, first self-care frequency was explored. In the initial step of the mediational analysis, self-care frequency and well-being were significantly, positively correlated (r = .228, p = .014), but self-care frequency and mindfulness were not (r =. 151, p = .079), indicating that mindfulness is not a significant mediator between self-care frequency and well-being. Thus the hypothesis that self-care and well-being are directly mediated by mindfulness is not supported.
Self-care Importance, Self-awareness, and Well-being. In the first step of the analysis of whether self-awareness mediated the relationship between self-care importance and well-being, it was found that self-care importance was significantly, positively correlated with well-being (r = .208, p = .014). In the second step, self-awareness and self-care importance were significantly, positively correlated (r = .325, p < .001). The third step indicated that self-awareness did not significantly account for the variance in well-being when self-care importance is controlled for ([R.sup.2] = .030, F[1,137] = 4.115, p = .045, Beta = .120, p = .183). Therefore, self-awareness was not a significant mediator in the relationship between self-care importance and well-being in mental health professionals, refuting the hypothesis.
Self-care Frequency, Self-awareness, and Well-being. To determine if self-awareness is a significant mediator of self-care and well-being in mental health professionals, self-care frequency was found to be significantly, positively correlated with well-being (r = .228, p = .014), but not with self-awareness (r = 104, p = .237), indicating that self-awareness did not significantly mediate the relationship between self-care frequency and well-being and offering no support for the hypothesis that the path from self-care to self-awareness to wellbeing is stronger than the direct path from self-care to well-being.
The purpose of this study was to examine the relationship between mental health professionals' self-care practices and general well-being by investigating the indirect effects of self-awareness (knowledge of one's thoughts, emotions, and behaviors) and mindfulness (awareness of and attention to oneself and one's surroundings). Some results were consistent with the predictions, in that self-care practices may have both direct and indirect effects on well-being.
As predicted, self-awareness and mindfulness were found to be significantly, positively correlated, which is consistent with previous studies (e.g., Brown & Ryan, 2003; Wall, 2005). Although these constructs seem similar and are correlated, it is important to note the differences between them. Specifically, self-awareness is considered to be knowledge of one's thoughts, emotions, and behaviors; mindfulness is maintaining awareness of and attention to oneself and one's surroundings. Our results suggest that when self-awareness increases, so does mindfulness, and vice versa. This adds support for the relationship between self-care importance, self-awareness, and well-being because mindfulness was found to be a significant mediator within the relationship.
Likewise, as hypothesized, mindfulness in mental health professionals was found to be a significant mediator of the relationship between self-care importance and well-being. Specifically, it appears that the link between perceived importance of self-care and well-being is indirectly affected by mindfulness. This suggests that, to receive the full benefits of well-being from perceiving self-care as important, one must achieve a state of mindfulness. Although few previous studies discuss these connections, the findings of this study are consistent with past research in that self-care importance and mindfulness have been shown to be associated (Christopher, Christopher, Duncan, & Schure, 2006), and mindfulness and well-being have also been found to be correlated (Brown & Ryan, 2003; Rosenzweig et al., 2003).
Further, because mindfulness is considered to be a purposeful state (Brown & Ryan, 2003; Shapiro et al., 2006), it may be that those who practice it believe in its importance and value being mindful, so that valuing of self-care activities may influence the intentional component of mindfulness. For example, an individual who values engaging in self-care activities, such as going for a nature hike, may also be better able to practice mindfulness. In addition, mindfulness is considered to be a state of being, rather than something individuals do (Rothaupt & Morgan, 2007), suggesting that belief in the value and importance of self-care may elicit a mindful state. These individuals may believe that self-care practices are important to enhance their well-being. For example, counseling students who found value and importance in self-care activities like yoga and meditation reported feeling more mindful and experiencing overall growth and wellness (Christopher et al., 2006). This indicates that the link between mindful and self-care behaviors, feelings, and outcomes may be important.
Notably, mindfulness was not found to be a significant mediator of the relationship between self-care frequency and well-being in mental health professionals. This suggests that the frequency of participation in self-care activities may relate to enhanced well-being without necessarily requiring a state of mindfulness. These findings do not support the present study's predictions. The fact that there is minimal literature connecting self-care frequency and mindfulness is reinforced by the fact that this study did not find self-care frequency and mindfulness to be significantly correlated.
Although these findings did not support the hypothesis, they have important implications. Specifically, the significant, positive correlation between self-care frequency and well-being indicates that increased participation in self-care activities is associated with increased general well-being. These findings are supported in the literature (e.g., Boero et al., 2005; Coster & Schwebel, 1997; Lustyk et al., 2004), which suggests that an increase in self-care activities increases well-being. Moreover, mindfulness does not influence the effects in this relationship, indicating that participation in self-care activities is associated with increased wellness, and mindfulness may not indirectly affect this relationship. This may indicate that self-care activities do not necessarily require awareness of self and surroundings; rather, the simple act of participation in self-care behaviors influences overall wellness.
The relationship between mindfulness and well-being may also be more complex than is examined here. For instance, for some individuals, mindfulness may enhance well-being, providing a sense of grounding and perspective, while, it may cause others to attend more astutely to personal struggles and negative aspects of their lives, causing a decrease in wellness.
The fact that self-awareness was not found to be a significant mediator of the relationship between self-care and well-being suggests that self-care appears to enhance one's well-being without necessarily requiring a state of self-awareness to intervene the effects in the relationship. These findings were the same for self-care frequency and self-care importance, which suggests that the predictions of this study were not supported. Nevertheless, self-awareness and well-being were found to be significantly, positively correlated, which suggests that with an increase in self-awareness, there is an increase in well-being. When thinking about these findings, it may be important to consider the relationship between self-awareness and well-being independent of self-care. Although research has so far found no link between self-awareness and well-being, this may be an important relationship. For example, insight-oriented psychotherapy tends to value the importance of insight and awareness as a means of enhancing mental health (i.e., well-being). Furthermore, though previous studies seem to indicate that self-awareness is enhanced through self-care, the relationship seems to be much more evident for psychological and spiritual aspects of self-care than for physical and support components (e.g., Coster & Schwebel, 1997; Hamilton & Jackson, 1998; Norcross, 2005; Valente & Marotta, 2005).
Self-care frequency and self-care importance were found to be significantly, positively correlated. This suggests that with more frequent participation in self-care activities, their perceived importance rises, and vice versa. It makes sense that individuals participate in activities they value. For example, Garfield and Kurtz (1976) discuss psychotherapists' beliefs in the importance of personal therapy, which influenced their decisions to enter treatment. Furthermore, self-care frequency and importance were found to be significantly, positively correlated with well-being, which is consistent with previous findings (Lustyk et al., 2004; Schnauzer, 2006; Valente & Marotta, 2005; Wong et al., 2006).
Self-awareness was found to be significantly, positively correlated with self-care importance but not frequency. This indicates that self-awareness may not be necessary to participation in self-care activities; however, awareness of the importance of these behaviors is key. Because self-awareness is described as "knowledge about the self," (Brown & Ryan, 2003, p. 823), it would seem probable that self-awareness would enable an individual to understand what may be important, including activities to better oneself.
Mental health professionals' frequency of participation in and views of the importance of self-care activities have been found to be significantly associated with their general well-being. In attempting to understand how self-care affects well-being, it was found that mindfulness (awareness of and attention to self and surroundings) indirectly influences the relationship between self-care importance and well-being but not the relationship between self-care frequency and well-being. This study also examined the role of self-awareness (knowledge of one's thoughts, emotions, and behaviors) in the relationship between self-care and well-being. Although no significant effects were found to explain self-awareness as an intervening variable in that relationship, it was found to be significantly associated with self-care importance and well-being.
Limitations and Future Research. This study had several limitations. First, the sample may have limited the findings. Because the surveys were mailed, those who returned them were self-selected. Any differences between individuals who returned surveys and those who did not could not be examined.
Social desirability may also have limited this research. Because mental health professionals help their clients increase general well-being, they may have been compelled to positively bias their reports of participation in self-care activities and overall wellness. Determining what an individual believes to be "'socially desirable' depends on one's reference group" (Kirkpatrick, 1993, p. 266). This suggests that what some mental health professionals consider socially desirable may not be considered socially desirable by other groups. Therefore, it may be appropriate for future research to explore social desirability.
Moreover, most of the sample were White women. This limits the generalizability of the results to that group. Page and colleagues (1997) suggest that men and women experience self-awareness differently, which may also affect the generalizability of the findings. Future research should therefore expand the sample to a more diverse group.
The sample has other limitations. For instance, participants reported working within a variety of settings, but there were too few participants in each job setting for the groups to be compared. The type of work setting may have significantly influenced reports of engagement in and value of self-care, but differences could not be assessed. Additionally, participants were graduate students, professionals, or both, but were not asked to specify their professional level. Their status may also significantly impact the reports of engagement in and value of self-care. Thus, it may be important for future research to explore how work setting and student/professional status may relate to self-care.
Implications for Counseling Practice. The results indicate that the frequency with which mental health professionals participate in self-care activities and the importance they place on them is associated with overall well-being, which suggests that self-care is important to the functioning of mental health professionals. Indirectly mindfulness also affects the relationship between self-care importance and well-being, which suggests that one who perceives self-care as important will receive the benefits of well-being after first achieving mindfulness. However, mindfulness may not be necessary for mental health professionals to achieve the benefits of actively participating in self-care.
Counselors are responsible for their own wellness and awareness of the effects they may have on their clients (ACA, 2005; AMHCA, 2010). Since they may be susceptible to impairment in their professional lives that has a negative impact on their clinical work (e.g., Coster & Schwebel, 1997), it is important for them to adhere to practices to enhance overall well-being. Counselors who wish to maintain and improve their personal wellness as well as their professional effectiveness are encouraged to explore their frequency of involvement with and perceptions of the importance of self-care. They are also encouraged to examine their state of mindfulness, which may further enhance their wellbeing. Like the programs developed by Christopher et al. (2006) and Schure et al. (2008), counselor training programs should explore the utility of developing self-care and wellness activities for their students within the curriculum. If self-care practices become part of their training, counselors may be more likely to participate and find the value in self-care.
American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: Author.
American Mental Health Counselors Association. (2010). Principles for AMHCA code of ethics. Retrieved on March 1, 2010, from https://www.amhca.org/assets/content/AMHCACodeOfEthics2010Final.pdf
Anderson, R. T., King, A., Stewart, A. L., Camacho, F., & Rejeski, W. J. (2005). Physical activity counseling in primary care and patient well-being: Do patients benefit? Annals of Behavioral Medicine, 30, 146-154.
Baron, R. M., & Kenny. D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.
Bishop, S. R. (2002). What do we really know about mindfulness-based stress reduction? Psychosomatic Medicine, 64, 71-84.
Bishop, S. R., Lau, M, Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., et al. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230-241.
Blais, M. A., Lenderking, W. R., Baer, L., deLorell, A., Peets, K., Leahy, L., et al. (1999). Development and initial validation of a brief mental health outcome measure. Journal of Personality Assessment, 73, 359-373.
Boero, M. E., Caviglia, M. L., Monteverdi, R., Braida, V., Fabello, M., & Zorzella, L. M. (2005). Spirituality of health workers: A descriptive study. International Journal of Nursing Studies, 42, 915-921.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822-848.
Byrne, H. (2007, June). Healing our wounds through mindfulness. Paper presented at the meeting of the Pennsylvania Psychological Association Annual Convention, Harrisburg, PA.
Callaghan, P. (2004). Exercise: A neglected intervention in mental health care? Journal of Psychiatric and Mental Health Nursing, 11, 476-483.
Carroll, L., Gilroy, P. J., & Murra, J. (1999). The moral imperative: Self-care for women psychotherapists. Women & Therapy, 22, 133-143.
Christopher, J. C., Christopher, S. E., Duncan, T., & Schure, M. (2006). Teaching self-care through mindfulness practices: The application of yoga, meditation, and qigong to counselor training. Journal of Humanistic Psychology, 46, 494-509.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159.
Coster, J. S., & Schwebel, M. (1997). Well-functioning in professional psychologists. Professional Psychology: Research and Practice, 28, 3-13.
Dishman, R. K. (2003). The impact of behavior on quality of life. Quality of Life Research, 12, 43-49.
Estanek, S. M. (2006). Redefining spirituality: A new discourse. College Student Journal, 40, 270-281.
Fenigstein, A., Scheier, M. F., & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of Counseling and Clinical Psychology, 43, 522-527.
Garfield, S. L., & Kurtz, R. M. (1976). Personal therapy for the psychotherapist: Some findings and issues. Psychotherapy: Theory, Research, Practice, Training, 13, 188-192.
Grant, A. M., Franklin, J., & Langford, P. (2002). The Self-Reflection and Insight Scale: A new measure of private self-consciousness. Social Behavior and Personality, 30, 821-836.
Guy, J. D. (2000). Holding the holding environment together: Self-psychology and psychotherapist care. Professional Psychology; Research and Practice, 33, 351-352.
Hage, S. M. (2006). A closer look at the role of spirituality in psychology training programs. Professional Psychology: Research and Practice, 37, 303-310.
Hamilton, D. M., & Jackson, M. H. (1998). Spiritual development: Paths and processes. Journal of Instructional Psychology, 25, 262-270.
Henderson, K. A., & Ainsworth, B. E. (2001). Researching leisure and physical activity with women of color: Issues and emerging questions. Leisure Sciences, 23, 21-34.
Hirst, I. S. (2003). Perspectives of mindfulness. Journal of Psychiatric and Mental Health Nursing, 10, 359-366.
Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Schapp, M. J., Cropley, T. G., et al. (1998). Influence of a mindfulness meditation-based reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUNA). Psychosomatic Medicine, 60, 625-632.
Kirkpatrick, L. A. (1993). Fundamentalism, Christian Orthodoxy, and intrinsic religious orientation as predictors of discriminatory attitudes. Journal for the Scientific Study of Religion, 32, 256-268.
Koocher, G. P., & Keith-Spiegel, P. (1998). Ethics in psychology: Professional standards and cases (2nd ed.). New York: Oxford University Press.
Lustyk, M. K. B., Widman, L., Paschane, A. A. E., & Olson, K. C. (2004). Physical activity and quality of life: Assessing the influence of activity frequency, intensity, volume, and motive. Behavioral Medicine, 30, 124-131.
Mackey, R. A., & Mackey, E. F. (1994). Personal psychotherapy and the development of a professional self. Families in Society, 75, 490-498.
Macran, S., Stiles, W. B., & Smith, J. A. (1999). How does personal therapy affect therapists' practice? Journal of Counseling Psychology, 46, 419-431.
Mahoney, M. J. (1997). Psychotherapists' personal problems and self-care patterns. Professional Psychology: Research and Practice, 28, 14-16.
Norcross, J. C. (2000). Psychotherapist self-care: Practitioner-tested, research-informed strategies. Professional Psychology: Research and Practice, 31, 710-713.
Norcross, J. C. (2005). The psychotherapist's own psychotherapy: Educating and developing psychologists. American Psychologist, 60, 840-850.
O'Connor, M. F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology: Research and Practice. 32, 345-350.
Page, R. C., McAuliffe, E., Weiss, J. F., Ugyan, J., Wright, L. S., & MacLachlan, M. (1997). Self-awareness of participants in a long-term Tibetan Buddhist retreat. Journal of Transpersonal Psychology, 29, 85-98.
Patterson, C. H. (1966). Theories of counseling and psychotherapy. New York: Harper & Row, Publishers.
Perrone, K. M., Webb, L. K., Wright, S. L., Jackson, Z. V., & Ksiazak, T. M. (2006). Relationship of spirituality to work and family roles and life satisfaction among gifted adults. Journal of Mental Health Counseling, 28, 253-268.
Pincus, J. (2006, November). Teaching self-care. Paper presented at the meeting of the Pennsylvania Psychological Association on the Ethics Educators Conference, Harrisburg, PA.
Roback, H. B. (1974). Insight: A bridging of the theoretical and research literatures. The Canadian Psychologist, 15, 61-88.
Rosenzweig, S., Reibel, D. K., Greeson, J. M., & Brainard, G. C. (2003). Mindfulness based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine, 15, 88-92.
Roth, B. (1997). Mindfulness-based stress reduction in the inner city. The Journal of Mind-Body Health, 13, 50-59.
Rothaupt, J. W., & Morgan, M. M. (2007). Counselors' and counselor educators' practice of mindfulness: A qualitative inquiry. Counseling and Values, 52, 40-54.
Saucier, G., & Skrzypinska, K. (2006). Spiritual but not religious? Evidence for two independent dispositions. Journal of Personality, 74, 1257-1292.
Schmidt, S. (2004). Mindfulness and healing intention: Concepts, practice, and research evaluation. The Journal of Alternative and Complementary Medicine, 10, S7-S14.
Schnauzer, M. (2006). Qigong: The art of self-healing. Perspectives in Psychiatric Care, 42, 5-54.
Schure, M. B., Christopher, J., & Christopher, S. (2008). Mind-body medicine and the art of self-care: Teaching mindfulness to counseling students through yoga, meditation, and qigong. Journal of Counseling and Development, 86, 47-56.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62, 373-386.
Sternberg, R. J. (2000). Images of mindfulness. Journal of Social Issues, 56, 11-26.
Stevanovic, P., & Rupert, P. A. (2004). Career-sustaining behaviors, satisfactions, and stresses of professional psychologists. Psychology: Theory. Research, Practice, Training, 41, 301-309.
U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2005). Physical activity. In Dietary guidelines for Americans 2005 (chap. 4). Retrieved April 7, 2007, from http://www.health.gov/dietaryguidelines/dga2005/document/
Valente, V., & Marotta, A. (2005). The impact of yoga on the professional and personal life of the psychotherapist. Contemporary Family Therapy, 27, 65-80.
Walen, H. R., & Lachman, M. E. (2000). Social support and strain from partner, family, and friends: Costs and benefits for men and women in adulthood. Journal of Social and Personal Relationships, 17, 5-30.
Wall, R. B. (2005). Tai chi and mindfulness-based stress reduction in a Boston public middle school. Journal of Pediatric Health Care, 19, 230-237.
Webb, W. M., Marsh, K. L., Schneiderman, W., & Davis, B. (1989). Interaction between self monitoring and manipulated states of self-awareness. Journal of Personality and Social Psychology, 56, 70-80.
Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J. (2000). Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, 109, 150-155.
Wong, Y. J., Rew, L., & Slaikeu, K. D. (2006). A systematic review of recent research on adolescent religiosity/spirituality and mental health. Issues in Mental Health Nursing, 27, 161-183.
Kelly C. Richards, C. Estelle Campenni, and Janet L. Muse-Burke are affiliated with Marywood University. Correspondence concerning this article should be addressed to Kelly C. Richards, Marywood University, Department of Psychology and Counseling, 2300 Adams Avenue, Scranton, Pennsylvania 18509-1598. E-mail: firstname.lastname@example.org.
Table 1. Descriptive Statistics and Pearson Correlations for Current Study's Scales Pearson Correlations Scale Mean (SD) SCF SCI SKIS 10 SCF 15.38 (3.75) -- SCI 20.77 (3.74) .335 *** -- SRIS 94.35 (12.96) .104 .325 *** -- Self-reflection 58.45 (10.75) Insight 38.71 (5.47) MAAS 4.28 (0.73) .151 .179 * .293 ** SOS-10 48.38 (7.25) .228 ** .208 * .174 * Pearson Correlations Scale MAAS SOS 10 SCF SCI SRIS Self-reflection Insight MAAS -- SOS-10 .541 *** -- Note. SCF = Self-care Frequency; SCI = Self-care Importance; SRIS = Self-Reflection and Insight Scale (Grant et al., 2002); MAAS = Mindful Attention Awareness Scale (Brown & Ryan, 2003); SOS-10 = Schwartz Outcomes Scale-10 (Blais et al., 1999) * p < .05 ** p = .001 *** p < .001 Table 2. Mediational Regression Analysis: Self-Care: Importance, Mindfulness, and Well-Being R [R.sup.2] Analysis One: Well-Being on Self-Care Importance .208 .043 Analysis Two: Mindfulness on Self-Care Importance .179 .032 Analysis Three: Step 1: Well-Being on Mindfulness .541 .292 Step 2: Well-Being on Self-Care Importance .552 .305 [R.sup.2] change Beta Analysis One: Well-Being on Self-Care Importance .208 * Analysis Two: Mindfulness on Self-Care Importance .170 * Analysis Three: Step 1: Well-Being on Mindfulness .520 ** Step 2: Well-Being on Self-Care Importance .013 .115 * = p < .05 ** = p < .001