Self-care and beyond: a brief literature review from a Christian perspective.

Tan, Siang-Yang ; Castillo, Melissa

Psychologists and psychology trainees face various challenges, including elevated risks of stress, burnout, and vicarious traumatization. Goncher, Sherman, Barnett, & Haskins (2013) endorse ongoing self-care as a foundational professional competency and an ethical imperative for practice (see also Barnett, Baker, Elman, & Schoener, 2007; Barnett, Johnston, & Hillard, 2006; Tan 2011). Self-care practice may be conceptualized as the engagement in thoughts, feelings, and behaviors that maintain and promote physical, emotional, social, and spiritual well-being. According to Charlescraft, et al. (2010): "Self-care addresses those elements of life that allow one to be well in a variety of ways spiritually, emotionally, physically and mentally--for the purpose of renewal and personal growth" (p. 18).

Self-care is crucial for the well-being of the counselor. It is also essential for the efficient, effective, and ethical practice of counseling, for the ultimate benefit and welfare of the client (see Norcross and Guy, 2007). Self-care is not "selfish care" or "self-centered care." "Self-care for the counselor, however, refers to healthy and wise strategies for taking good care of oneself as a counselor in order to manage stress well and prevent burnout.... It is.... loving and wise to engage in proper self- care that eventually leads to the helping and healing of others" (Tan, 2011, p. 19).

Self-care strategies for the professional and personal self are intimately related. Professional and personal self-care involves ongoing self-awareness and active self-assessment and the use of helpful self-care strategies. However, a Christian perspective on and biblical critique of self-care is also needed.

Self-Care for Counselors

Recently, several helpful recommendations and challenges have been noted in the self-care literature. Goncher, et al. (2013) endorse the use of 12 ongoing self-care strategies by psychologists and psychology trainees in order to manage inherent professional stresses and challenges, including: "valuing the person of the psychotherapist, refocusing on the rewards of the practice of psychology, recognizing occupational hazards, minding the body, cultivating and nurturing supportive relationships, setting boundaries, cognitive restructuring, sustaining healthy escapes, creating a flourishing environment, personal psychotherapy, cultivating spirituality and mission, and fostering creativity and growth (see Norcross & Guy, 2007, for a comprehensive review)" (p. 57).

Wise, Hersh, and Gibson (2012) advocate for a comprehensive and reciprocal process of self-care, inspired by Rabbi Hillel's philosophy "If not now.. .when?," that includes mindfulness practices, values- oriented acceptance-based therapies, and positive psychology based on the following four principles: aspiring to flourish with emphasis on resilience building strategies (in contrast to a survival strategy that barely maintains the status quo and prevents negative stress reactions), intentional selection of a long- term self-care plan, awareness and practice of reciprocity in care of self and others, and the integration of self-care strategies into the professional lifestyle (in contrast to adding additional "to do's on top of already stressful and hectic schedules). In addition, Cohn and Hastings (2013) identified the navigation of culturally appropriate boundaries among members of the community and boundaries between professional and personal roles as critical self-care strategies.

Skovholt (2001) recommends the following self-care strategies for sustaining and nurturing the professional self of the counselor: avoiding the impulse toward grandiosity; thinking long-term; putting together and actively applying an individual development method or plan; cultivating professional self-understanding; creating a professional greenhouse (environment for growth) at work; having leadership that facilitates balance between self-care and caring for others; drawing on professional social support from peers; getting support from bosses, supervisors, and mentors; learning how to be playful and professional; releasing emotions of distress through professional venting; understanding the reality of early professional anxiety; reinventing oneself to increase excitement and reduce boredom; dealing with ambiguous professional loss by minimizing it; learning to refuse unreasonable requests (see Skovholt 2001, pp. 206-7, pp. 130-44). Skovholt also lists the following ten activities for self-care for sustaining the personal self of the counselor: " 1) Spending time with family, 2) Job skills training or education, 3) Pursing a fun hobby, 4) Engaging in physical activity, 5) Reading, 6) Receiving supervision or consultation, 7) Socializing at work, 8) Spending time alone, 9) Spending time with friends, partner, or spouse, and 10) Taking a vacation" (p. 212).

Pearlman and Maclan (1995) reported the following as the top ten helpful strategies for selfcare for trauma therapists: discussing cases with colleagues; attending workshops; spending time with family or friends; enjoying travels, vacations, movies, hobbies; talking with colleagues between sessions; socializing; exercising; controlling case load; developing spiritual life; and receiving supervision in general.

Mahoney (2003) offers several helpful recommendations for therapist self-care within the context of doing constructive psychotherapy: "1) Be gentle with yourself; honor your own process, 2) Get adequate rest, 3) Make yourself comfortable, 4) Move your body often, 5) Develop a ritual of transition for leaving work at the office, 6) Receive regular professional massages, 7) Cherish your friendship and intimacy with family, 8) Cultivate your commitment to helping; honor the privilege of our profession, 9) Ask for and accept comfort, help, and counsel (including personal therapy), 10) Create a support network among your colleagues, 11) Enjoy yourself, 12) Follow your heart and embrace your spiritual seeking" (pp. 260-61).

In some recent research on self-care and burnout, one study of 363 psychology predoctoral interns found that the most effective self-care strategies used in the internship year were: receiving social support from family and friends, seeking pleasurable experiences, and cultivating humor (Turner, et al., 2005). In another study of 595 professional psychologists, survey results showed that the following six strategies were highly important to all of them: maintaining a sense of humor; maintaining self-awareness or self-monitoring; maintaining balance between personal and professional lives; maintaining professional identity and values; engaging in hobbies; and spending time with spouse, partner, or family (Rupert & Kent, 2007).

Self-Care for Chaplains and Pastors

Burns, Chapman, and Guthrie (2013) endorse self-care to be a prominent theme in resilient ministry. The authors note, "The idea of self-care involves the pursuit of physical, mental, and emotional health. While just as important as spiritual formation, self-care may initially sound selfish...but in truth, responsible self-care is actually a way to deny oneself ... The old life may have included slothful or obsessive activities such as inconsistent sleep habits, crazy work hours, poor or neurotic exercise, and an unhealthy diet. Self-denying selfcare, on the other hand, may include getting to bed on time, saying no to work by setting aside time for Sabbath and sabbatical, getting responsible exercise, and eating a balanced diet" (p. 21).

Stuart (2012) views self-care to be an essential practice in professional ministry and reminds us that the Council on Collaboration, which includes the Association of Professional Chaplains, contains the competency requirement that a candidate for certification will demonstrate the ability to "attend to one's physical, emotional and spiritual wellbeing" (p. 33). Stuart reports the awareness of stressors and regular spiritual practice of a contemplative nature during the day are helpful tools to cope with stress and maintain health. He suggests taking short breaks during the day to retreat to the chapel for lectio divina, taking a walk outside for a moment of prayer in the prayer garden, or listening to music in the hospital lobby. After work, Stuart exercises regularly at the local gym, has monthly meetings with a spiritual director, and gets a full body massage every two months.

Carter (2013) reports that North American ministers have increasing rates of stress and burnout. As a result, "their physical, mental, emotional, and spiritual health is deteriorating at an alarming rate. One way of addressing this problem has been to emphasize clergy health and to encourage ministers to be more intentional about implementing self-care strategies" (p. 13). Why do pastors undervalue self-care? Burns, Chapman, and Guthrie (2013) note that research has suggested pastors either hold unrealistic expectations of human productivity, don't view self-care as an ethical imperative, or "spiritualize away" their need for self-care. Are Christian counselors and psychotherapists also susceptible to these notions? Several authors endorse self-care as an ethical obligation (Tan, 2011; Wise, Hersh, & Gibson, 2012). The Australian Psychological Society's (2007) Code of Ethics states that psychologists must ensure "that their emotional, mental, and physical state does not impair their ability to provide a competent psychological service" (p. 19). As a result, Barnett and Cooper (2009) advocated for the creation of a self-care ethos among professional psychologists "that emphasizes efforts to maintain psychological wellness at every phase of each psychologist's career" (p. 17).

A more recent study of burnout in Catholic clergy with a sample of 2,482 Catholic priests across the United States, however, found that they scored significantly less burned out than the norm groups on the Maslach Burnout Inventory, and concluded: "For Catholic priests and likely for all people, strong psychological and spiritual support systems seem to be most important in preventing burnout, especially for those engaged in the demanding positions of caring for others" (Rosetti & Rhoades, 2013, p. 335).

Burns, Chapman, and Guthrie (2013) believe self-care is so critical that they assert self-care to be synonymous with spiritual formation. All Christians are greatly influenced physically, emotionally, and spiritually by the practice of self-care--as Christian identity is rooted in being worshippers of God, which includes servanthood. Therefore, self-care is a needed imperative to assess and address professional challenges, difficulties, and idols in the lives of the counselors, psychologists, chaplains, pastors, and of all Christian persons for health and well-being (e.g. Is our work consistent with our identity as Christ followers/worshippers or are some aspects and burdens in our professional lives the result of our own sinful desires such as pride, self-dependence, self-sufficiency, independence from God's will and ways?). Let us assess our lives with sober judgment, dependent upon the Spirit for wisdom and discernment, to identify any idols that hinder our lifestyle of worship and ultimately, our holistic health as disciples of Christ. Identifying and surrendering idols is one avenue of "self-care" to maintain and increase health.

A Biblical Perspective on Self-Care

The Bible offers various insights about self-care. Self-care for the Christian counselor, as for any counselor, is in general, an essential and biblically sound aspect of the experience and person of the counselor or psychotherapist (Tan, 2011). Tan (2006) has noted: "In the midst of his busy ministry, meeting the needs of many people, Jesus regularly took time off to be in solitude and to pray, to be in communion with the Father by the power of the Holy Spirit (Matt 14:23; 26:36; Mark 1:35; 6:46; 14:32; Luke 5:16; 6:12; 22:41; John 17:1; Heb 5:7). This was the secret of transforming power in Jesus' life and ministry. It is also the secret of transforming power for us in our lives and ministries" (p. 34). Nine ways of experiencing rest that are relevant to appropriate self-care include: shepherd-centeredness in Christ that involves abiding in Christ (John 15:5), Spirit-filled surrender such that one fully submits oneself to the Lordship of Christ, solitude and silence, simplicity, Sabbath-keeping, sleep, spiritual community, servanthood, and stress management from a biblical perspective that promotes love and humility rather than competition and pride (Tan, 2003).

Traditional or classical spiritual disciplines such as prayer, Bible study and meditation, solitude and silence, fasting, worship, confession, fellowship, submission, service, and simplicity (Tan & Gregg, 1997) can therefore help prevent burnout as well as facilitate spiritual growth and Christlikeness (see Tan, 2011). Another category of spiritual disciplines are the following authentic disciplines or experiences initiated by God to shape us and work God's will in our lives (Thomas, 2002): Selflessness, waiting, suffering, persecution, social mercy, forgiveness, mourning, contentment, sacrifice, hope and fear. These circumstantial spiritual disciplines stretch us and may knock us out of balance at times, but lead to spiritual maturity and growth that is similar to benefit-finding, post-traumatic growth (or stress-related growth) and meaning making. Therefore, trying to keep our lives in balance all the time in order to engage in self-care may be misleading in overemphasizing balance. Canning (2011) has appropriately and biblically critiqued this "balance" view of self-care. She hesitates to practice and teach such "self- care" because we need to go beyond balanced self-care to stewardship and sanctified suffering that at times may stretch us and knock us out of balance. At such times, we need to trust in God's sovereign provision and grace for us, and thus in "God-care" for us!

Doehring (2013) offers a self-care online course for pastors and theological students serving Christian and Jewish communities based on current research on self-compassion (Barnard & Curry, 2012), will power (Baumeister & Tierney, 2011), and habits (Duhigg, 2012). In this course,

   Journal reflections and group interactions
   make (students) spiritually and
   theologically accountable for their
   coping and self-care. They are able to
   claim with more clarity espoused
   beliefs about who God is. Their
   espoused beliefs are incorporated into
   spiritual practices that often (1) counteract
   embedded judgmental beliefs
   about stress and self-care; (2) address
   ambivalence about change; and (3)
   support change in stress-relieving
   habits. These changes in spiritual and
   self-care practices, along with changes
   in their theological understanding of
   stress and self-care, make them
   resilient to debilitating spiritual struggles
   experienced internally, interpersonally,
   or in their relationship with
   God or the sacred. (pp. 625-626)

Sanctified Suffering, Posttraumatic Growth, and Resilience

The Bible also offers various insights on suffering (see Keller, 2013), posttraumatic growth, and resilience (see Tan, 2013). A biblical, Christian perspective on sanctified suffering will be Christ-centered and "focus on sharing in the fellowship of Christ's sufferings (Phil. 3:10) in union and communion with Him" (Tan, 2013, p. 363). It will also emphasize outcomes such as God's power being made perfect in one's weakness (2 Cor 12:9,10), brokenness, humility, and spiritual growth into deeper Christlikeness rather than greater independence and self-reliance (Tan, 2013). Suffering can increase dependence upon God, teach humility, provide experiences and wisdom with which to later comfort others, and refine qualities such as patience and thankfulness with regard to Christlikeness (see Tan, 2006, p. 77). Weakness is the way in the Christian spiritual life (Packer, 2013), instead of self-sufficiency which can lead to pride.

With regard to posttraumatic growth and resilience, Meichenbaum (2012, pp. 191-196) describes several ways to enhance resilience in areas of physical fitness, interpersonal fitness, emotional fitness, thinking fitness, behavioral fitness, and spiritual fitness. In a similar manner, Joseph (2011, pp. 175-204) presents six signposts to facilitating posttraumatic growth based on the THRIVE model: 1. Taking stock, 2. Harvesting hope, 3. Reauthoring, 4. Identifying change, 5. Valuing change, and 6. Expressing change in action (pp. 175-176). Tan (2013) has provided a summary of these ways of enhancing resilience (Meichenbaum, 2012) and the six signposts to facilitating posttraumatic growth (Joseph, 2011), and a biblical perspective on resilience and posttraumatic growth.

Beyond Self-care to Stewardship and Sanctified Suffering

As Christian human beings, we are aware that all that we are, do, and have, even our very breath and life, comes from God. Apart from God, we can do nothing. We must therefore abide in Christ, in union and communion with Him--He is the vine and we are the branches (John 15:5). A lifestyle of worship directed towards the living God is a posture of health; it's what we were created to be and how we were created to live in relationship with God and others in the world. Abiding in Christ, as members of his body, also involves interdependency. Empowered by Christ through the Holy Spirit and supported by one another, we can care for one another and carry one another's burdens (Gal. 6:2). By God's grace, we serve one another as good stewards of God's resources (Canning, 2011). As children of God and members of the body of Christ, we give to and receive from God and others. Reciprocal caring goes beyond "self"-care to what one may recognize as "we"-care or "community"-care.

Let us not be so self-sufficient, independent, and prideful to think that we can care for others and ourselves in our own strength. A Christ-centered model of counseling involves being dependent upon Christ and interdependent in Christian community serving God and others as well as receiving from God and others. As God works through us to heal, redeem, and refresh others, so God works through others to heal, redeem, and refresh us. McMinn's (1996) comprehensive map of psychological and spiritual health guides us towards a comprehensive and reciprocal picture of Christian self-care: "An accurate sense of self allows us to recognize our responsibility to God, others, and ourselves. Having a healthy awareness of brokenness keeps us humble and helps us fight our natural propensity towards self-centeredness. Healing relationships allow us to experience grace in the midst of life's trials" (pp. 44-45)

We therefore need to go beyond self-care to stewardship of God's resources that involves conserving or preserving as well as using or spending such resources, depending on the seasons of our lives in the context of God's will for us (see Canning, 2011). We also need to go beyond selfcare to embracing sanctified suffering that can at times stretch us and knock us off balance so that we may grow to become more Christlike and spiritually mature.

Beyond "self"-care--or beyond our abilities to care for ourselves--is God's desire to care for us through friendship with Christ and through friendships with others in Christian community. Beyond self- care is "God-care" for us, and "we-care" or "community-care" in the body of Christ for one another, where healing relationships, role-models, accountability, bearing one another's burdens, and other interdependent maturing aspects of spiritual formation promote health, growth, and resilience. Burns, Chapman and Guthrie (2013) highlight social self-care as an essential aspect of health and spiritual formation, in addition to healthy boundaries, Sabbath rest, and discernment regarding physical care. Healthy limit and boundary setting are needed so that the good work God intends to be a blessing in and through our lives does not seem to be a curse on account of human obsessive, overworking, or isolating tendencies. Burns, Chapman, and Guthrie (2013) recommend caution with regard to following secular cult ideas of beauty and fitness, but still remind us that "poor physical health translates into less effective ministry" (p. 98). The authors assert: "Self-care is not selfish. It is a necessary part of staying involved in fruitful ministry for a lifetime." (p. 100). This discussion about self-care would greatly benefit from a more detailed engagement with Christian theologies of work, suffering, and spiritual gifts, in light of the unique constellation of experiences, cultures, and environments that compose the body of Christ.

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Siang-Yang Tan and Melissa Castillo

Fuller Theological Seminary

Siang-Yang Tan, Ph.D. (McGill University) is Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA, and Senior Pastor of First Evangelical Church Glendale in Glendale, CA. He has published numerous articles and 13 books, the latest of which is Counseling and Psychotherapy: A Christian Perspective (Baker Academic, 2011).

Melissa Castillo, M.A., is a Ph.D. candidate in Clinical Psychology at the Graduate School of Psychology at Fuller Theological Seminary. Her research interests include the integration of psychology and Christian faith, health psychology, trauma, and resilience.

Correspondence concerning this article should be addressed to: Siang-Yang Tan, Ph.D., Professor of Psychology, Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101; siangyangtan@fuller.edu