What is holding us back from caring for ourselves?

Sarah Kuipers, Stress management coach, trainer, and author

Sarah Eagger, Retired psychiatrist

Published in JHH 18.2-Frontiers of self-care

After working as a naturopath, hypnotherapist and life coach for many years, burnout finally forced me to stop work. A three-month sabbatical gave me time to heal body, mind and spirit, and prompted me to complete a masters in research to study stress and burnout in health professionals. I currently teach courses in personal development and stress management to medical students, and my book, The Thriving Giver, helps health professionals unearth the deeper roots of poor self-care, manage stress, and avoid the pitfalls of burnout.

Sarah Kuipers

I am a retired consultant NHS psychiatrist with a longstanding interest in holistic medicine, especially its spiritual component. Currently chair of the Janki Foundation for Spirituality in Healthcare, I also serve on the executives of both the Royal College of Psychiatrist’s Spirituality Interest Group and the religion and spirituality section of the World Psychiatric Association. Through my own training as a certified mindful self-compassion teacher, my understanding of radical self-care has grown immensely.

Sarah Eagger

Even before the pandemic struck, high levels of stress and burnout in health professionals had been amplified by systemic failures of government policy and patients’ ever-increasing expectations. Other factors appear to suggest that healthcare workers, while excelling in taking care of others, might be less attentive in looking after themselves. This article explores some of the deep and largely unconscious resistance to self-care and explains how self-compassion practices might address the underlying roots of poor self-care and help mitigate seemingly unmanageable stress and burnout.

Introduction

Throughout the Covid-19 pandemic, health professionals have been stretched to the limits. Many, confronted daily with death, trauma, suffering and distress are feeling exhausted and overworked. A survey carried out by the British Medical Association (2020) showed that 44% of doctors were suffering from anxiety, stress, burnout, depression, or other mental health conditions directly relating to, or amplified by, their work. Similarly, another survey during the pandemic found that 52% of nurses were concerned about their mental health (Royal College of Nursing, 2020). However, even before the pandemic, one research study carried out in 2019 suggested that 31% of UK doctors were experiencing high scores for burnout (McKinley et al, 2020). Now, more than ever, there is a need for a radical approach to self-care which addresses the deeper question of what is driving health professionals to care for others more than themselves. Only when we overcome the barriers that prevent us from fully valuing and caring for ourselves can we continue to work effectively and prevent ourselves from becoming disillusioned, depleted, or emotionally hardened.

A simple self-care prescription encouraging practitioners to exercise, relax, get social support, or develop a mindfulness or meditation practice may be too simplistic. Those strategies are valuable, but will only give short-term relief unless we address the deeper issue: what is holding us back from valuing ourselves?

This was one of the questions I (SK) wanted to answer after experiencing burnout myself. Ironically, as a hypnotherapist and life coach, I had been helping my clients master stress and balance their lives for many years, but I failed to practise what I preached. Bringing up three boys as a single mother alongside running a successful practice meant that my life had been incredibly demanding. So what had held me back from taking care of my own wellbeing?

Identifying the barriers to self-care

One area of research that intrigued me (SK), was Grosch and Olsen’s (1994) work highlighting the need to investigate family of origin when exploring barriers to self care. Even though their work focused primarily on psychotherapists, it appeared equally relevant for many health professionals. Reflecting on my own childhood, I could see how my unconscious need to be loved, wanted and accepted, led me to adopt the role of people pleaser. Focusing on keeping everyone else happy, I learned to value other people’s needs more than my own. Even though I was fortunate to grow up in a happy, functional family, I still failed to develop a healthy sense of self-worth. My tendency to put others first and ignore my own needs was a strong contributory factor in my burning out.

One study of 91 nursing students from two different nursing schools showed that 69% of those surveyed had been raised in a dysfunctional family with problems related to alcoholism, sexual abuse or physical violence. 74% of those surveyed also reported traits of codependency (Holder et al, 1994). Having experienced traumatic events in their own lives, those nursing students, like many working in healthcare, may have been drawn to the profession through their desire to relieve the suffering of others. However, growing up in dysfunctional families, their own needs for security, safety, love, or sense of belonging were unlikely to have been met. Indeed, they may from a young age have learned to focus on the needs of others, rather than paying attention to their own wellbeing and in so doing unwittingly adopted the role of caretaker, peacemaker, listener or fixer. Later in life, their lack of self-worth may well have led them to care for others more than themselves. Yet when we only value ourselves according to what we do for others or for how hard we work, it becomes so easy to over-extend ourselves and ignore our own needs. Learning to identify these unhelpful patterns is perhaps the most the important aspect of radical self-care.

Burnout: a catalyst for change

The story of a coaching client of mine, Elizabeth (name changed) demonstrates this further. Having received the Nurse of the Year award for her dedication and compassion in turning around a failing area of the hospital, Elizabeth was committed to ensuring that all patients and staff on her team were well cared for, but she paid little attention to her own needs until she burnt out and had to take three months off work. During one of our sessions Elizabeth, reflecting on her life, became aware of how everyone else had always come first – her patients, staff on the ward, her daughters and ex-husband. In allowing managers to phone her on days off, and always agreeing to work extra shifts when needed, she had looked after everybody else, except herself.

By creating new beliefs that gave her permission to say ‘no’ to unreasonable requests and that encouraged her to value herself, she was able to begin to create a more balanced and nurturing life. On returning to work she set clearer boundaries with her managers. She now asks other nurses to cover for her when she needs a break. Having learnt to balance her own needs with those of others, her patients receive better care, and she sets a great example of self-care for the team.

Freeing your mind from early programming

Our threat/defence and doing/getting systems are set in motion when we are under pressure (Gilbert and Choden, 2014), but we also have a soothing system that is activated by loving and kind thoughts. It uses the neurochemical system of oxytocin and endorphins – the ‘feel good’ brain transmitters. Owing to various life experiences, many people find this system is under-developed, because of beliefs and behaviours developed when young that still influence how they live their lives decades later. In the first seven years our minds are like sponges, absorbing information from our experiences and the actions and responses of our parents, siblings, and others. The character traits and roles we adopted in childhood may have kept us safe or helped meet our unconscious needs for approval, appreciation, or being loved or liked. If, in childhood, we adopted the role of caretaker or peacemaker, or were rewarded for being good, helpful, or for how hard we worked, we may not have learnt to value ourselves. However without a healthy sense of self-worth it can be incredibly difficult to balance our own needs with the care of others. When our intrinsic nature is to give, we can often find it hard to receive, and later in life this can lead us to over-extend ourselves for others and ignore our own needs. Equally if we never learned to express our wants and needs, set clear boundaries, or handle conflict, we will find it much harder to create the time and space to nurture ourselves.

Harsh inner critic

Another common childhood pattern – that of the ‘harsh inner critic’ – is particularly prevalent in healthcare professionals. Jenny Firth Cozens (2020) noted that self-criticism was found to be strongly linked to doctors’ depression, and those who were self-critical as students were more likely to become depressed later in their careers. She also confirms that doctors experience higher levels of psychological distress and use of alcohol than most other professionals perhaps because the work and its responsibilities are inherently stressful; add to this the vicarious trauma of others’ suffering and unhelpful organisational practices. Yet we nonetheless blame ourselves for things when they go wrong, putting ourselves down if we feel we have failed or made a mistake, and expecting to have coped better. In spite of difficult situations beyond our control, we add insult to injury by feeling guilty for our shortcomings. For a whole variety of reasons, we healthcare workers can be very unkind towards ourselves, but does this sort of attitude actually help us when we are suffering?

I (SE) learnt to recognise this pattern more deeply in myself when I went on a mindful self-compassion retreat as a gift to myself when I retired from the NHS. I wish I had gone to one sooner. For me it was a crash course in radical self-care where my early childhood patterns became clearer and I learned methods for responding to them in a more constructive way. On the verge of becoming a burnt-out doctor I realised how, as a healthcare provider, I really hadn’t been so good at looking after myself despite having practised meditation for many years and being a firm believer in holistic medicine. The course was originally devised by two American psychologists, Christopher Germer and Kristen Neff (2019). They have drawn on Buddhist ideas but also modern science and psychological frameworks. I was very touched by the experiential way they taught the course. There was some theory but the most powerful parts were the practical exercises that meant your own realisations emerged from experience. What also struck me was the importance they placed on the safety of the group. I think this aspect allowed us to go deeply into our own experiences and learn how to face our pain with kindness.

Self-compassion

The capacity to extend kindness towards ourselves and others when we are suffering is known as compassion. Compassion is an energetic force (which some would describe as arising from our true spiritual nature of love), that can lessen, soothe and calm our experience of suffering. As health workers we know compassion to be a desirable quality to have because it involves so many relevant qualities and skills. It means noticing suffering and attending to it, understanding what might be causing it – or at least being curious about it, being able to empathise or to some extent feel or touch upon another’s distress and crucially, taking action to relieve that suffering (Atkins & Parker, 2012).

If compassion is our capacity to notice the distress, pain, grief or anguish of another and to respond in a loving way, then what about when I am the one who is suffering? We all have times in our lives when we make mistakes, fail, or when bad things just happen to us. If a friend or loved one were in the same situation, we would usually respond in a kind way, with soothing, reassuring words, a gentle touch or a hug. Yet, when we are suffering, it is often much more difficult to respond to ourselves with the same kindness. Often our harsh inner critic tells us to ‘pull ourselves together’ or to ‘stop being so weak.’ Instead of being kind to ourselves, we amplify our pain by speaking to ourselves in an unkind way or by resisting the situation.

Stressing ourselves out

It is important to understand that negative self-talk and self-criticism trigger the same threat/defence responses as an external threat. With this disempowering thinking style we are literally ‘stressing ourselves out’. The self-critics may have been early caregivers whose voices we have internalised, or our wider culture or community, or arise from some learned need to protect ourselves from perceived threats. This inner critic might be aiming to protect us, but its judgemental and narrow stance is ultimately self-destructive. A first step towards developing kinder ‘self-talk’, is by becoming aware of our tone of voice and the language we use when speaking to ourselves. We might notice that we frequently berate ourselves with words like should, ought and must. Instead, we need to listen to a kinder inner self that has a more understanding voice. This compassionate part of ourselves can motivate us to change by being a supportive coach rather than a harsh parent.

Feel it to heal it

We are used to distracting ourselves with activity, or we may have become so accustomed to uncomfortable feelings that we are not even aware of them anymore. How often do we monitor our well-being and notice when we are under pressure or becoming stressed? When we become more conscious of our own levels of distress, pain and trauma, we can start trying to direct feelings of kindness and care towards ourselves. We are all in the ‘human-being boat of suffering’ together, even though it can feel like we are alone. The fact that we all suffer in our lives actually connects us. Practicing self-compassion allows us to focus our energy and attention on how we might alleviate our pain in a healthy way and activate our innate soothing system to mitigate the damaging mental and bodily systems aroused when we feel afraid or upset.

Though we all have an innate tendency to care and love, it seems that we need to cultivate the habit of being kind towards ourselves intentionally. We all have the ability to act compassionately towards others but often it doesn’t occur to us to direct those same feelings/energies towards ourselves when we are in pain. So, how do we boost this soothing system, given that it isn’t easy to be present with painful thoughts and emotions. However, we can learn and practise ‘warming up’ our response to these painful experiences and turn towards them with feelings of kindness and compassion. Actively doing this has been shown to reduce the incidence of depression and anxiety and make the experience of ‘being human’ easier to bear (Johnson & O’Brien, 2013).

Activating self-compassion

We may have noticed when someone else is distressed that our natural response is to reach out and give them a hug or stroke their back, arm or face. Imagine what your response is to a small child who has fallen over. Gentle words and tone of voice, soothing touch, physical warmth and a smile are also universal triggers for self-compassion. We all have gestures or movements that are self-soothing when we are troubled, but perhaps we hadn’t even noticed we were using them: simply stroking ourselves gently where it feels soothing will help to trigger a self-compassion response.

The soothing system

By turning our attention deliberately to cultivating self-soothing, we can move away from being driven by threat or instant gratification towards self-awareness, self kindness and connecting with others. Activities such as meditation, walking in nature, or creative pursuits can initiate the soothing response. Self-compassion practices can be used ‘in the moment’ or ‘on the job’. For health care workers it’s about including yourself in the ‘circle of compassion’ – so that at the same time as caring for others you are also caring for yourself. For instance, I, (SE), found the following very useful when being with those who felt suicidal. I could practise breathing in compassion for myself and breathing out compassion for them. This enabled me to stay present and attend to their needs whilst acknowledging to myself that this wasn’t easy, and I needed looking after as well.

Making choices

Acting compassionately towards ourselves means making choices that will contribute to our physical, mental and emotional health in the long term. This may involve self-discipline for changing behaviours, but doing this out of love for ourselves. For those of us in these stressful professions, it may mean choosing our hours and patterns of work more consciously and making choices that actively support our own wellbeing: for example, creating ‘boundary rituals’ between home and work, reducing the number of clinical shifts, working part time, and actively assigning time to relax and replenish. One GP asked their practice manager for longer consultation times for each patient, even though it meant a reduction in income. Another element of radical self-care is to give ourselves permission to seek and receive help: acknowledging our vulnerability can be a very challenging step for those whose work involves helping others.

Empathy or compassion fatigue?

Something too often called ‘compassion fatigue’ is actually ‘empathy fatigue’. Different parts of the brain are activated in these two experiences. Compassion is an energising, activating force that does involve a degree of empathy… but not too much! Consciously understanding and experiencing the differences can help direct our energy in a self-caring manner and help protect us from burnout. Many healthcare workers have generous hearts, high ideals, and a genuine desire to make a difference in the world. But their high levels of empathy may make them more prone to vicarious trauma and burn out. It doesn’t help to become an emotional sponge, resonating with a lot of painful feelings all the time. In fact, most meditation teachers say that you only need to ‘lightly touch’ another person’s pain to empathise with them.

In conclusion

The crucial first step into radical self-care depends on developing an awareness of any unexamined patterns related to self-sacrifice, excessive caring for others, self-criticism or overwork. It’s only when we unearth the roots of poor self-care and release those disempowering behaviours that we can begin to shift our priorities and start to value ourselves. We also need to learn to develop an attitude of self-compassion. Unless we do that, nothing will change. Radical self-care means being aware of, and addressing, vulnerabilities and self-defeating behaviours.

Only when we value ourselves as much as we value others will we able to manage high levels of pressure or stress. Once we recognise those disempowering patterns and are ready to address them, self-compassion practices open a doorway into healthy and constructive ways of responding to our own pain and stress, so we can enhance our wellbeing and avoid burnout.

Our books

We have both spent our lockdown days fruitfully putting our experiences into two books – Stillness in the Storm by Jan Alcoe and Sarah Eagger and The Thriving Giver by Sarah Kuipers. They are both reviewed in this issue and we hope they will give you further insights and tools to contribute to your radical self-care.

Acknowledgments:

A big thank you to Arnold Desser for editing this article.

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  • British Medical Association (2020) Stress and burnout warning over COVID-19. Available at: www.bma.org.uk/news-and-opinion/stress-andburnout-warning-over-covid-19 (accessed 4 June 2021).
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  • Gilbert P, Choden. Mindful compassion: How the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications.
  • Grosch W, Olsen, D (1994) When helping starts to hurt: a new look at burnout among psychotherapists. Norton.
  • Holder L, Farnsworth B, Wells D (1994) A preliminary survey of co-dependency traits and family of origin status of nursing students. Addictions Nursing, 6, 76–80.
  • Johnson EA, O’Brien KA (2013) Self-compassion soothes the savage EGO-threat system: Effects on negative affect, shame, rumination and depressive symptoms. Journal of Social and Clinical Psychology, 32(9) 939–963.
  • McKinley N, McCain R, Convie L, Clarke M, Dempster M, Campbell W, Kirk S (2020) Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study. BMJ Open, 10, e031765.
  • Royal College of Nursing (2020) Submission to the Commons Health & Social Care Committee inquiry on Workforce Burnout and Resilience in the NHS & Social Care. Available at: www.rcn.org.uk/about-us/our-influencing-work/policy-briefings/conr-932016/9/20 (Accessed 4 June 2021).

Resources

  • Stillness in the storm – 7 tools for coping with fear and uncertainty, Jan Alcoe and Sarah Eagger. Available at Stillness in the Storm – The Janki Foundation.
  • The thriving giver: 7 principles for health professionals and caregivers to enhance self-care and prevent burnout, Sarah Kuipers. JHH readers can order a copy at 25% discount off the £12.99 RRP, with free p&p in UK. Go to https://practicalinspiration.com/book/thethriving- giver and enter code THRIVING25.
  • Audio tracks of self-compassion meditations available on Sound cloud at https://soundcloud.com/centerformsc/sets/sarah-eagger. Center For MSC.
  • Mindful self-compassion UK – MSC training and retreats mindfulselfcompassionuk.com.
  • BFC Compassionate Care & Mindful Medicine https://ccmm.care/index.php/international-compassion-communitymembership/
  • Free eBook: Compassion. Bridging practice and science by Tania Singer and Matthias Bolz describes existing secular compassion training programmes and empirical research as well as the experiences of practitioners at www.compassion-training.org
  • Compassion Practices: Liberating Compassion for All.
  • Welcome – The Janki Foundation.
  • Happidote – The Janki Foundation – A free meditation app for health and social care professionals and caregivers.