Promoting Thriving for Therapists

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Promoting Thriving for Therapists : An Integral Perspective – Vivian Baruch, B.A; M. Couns.

Abstract: This article explores an integral approach to self care. It investigates an AQAL approach to promoting thriving and well-being in our work as therapists. Fatigue is an all-quadrant issue. As such, the dimensions of care for therapists must be Integral, encompassing all quadrants, levels, lines, states, and types, by creating an individualised ILP . It aims to maximise our overall well-being by preventing the negative impacts of our work as well as developing our various capacities through a comprehensive approach to self-care . An Integral approach to self-care recommends picking one or two practices from each of the five modules to be explored (body, mind, spirit , shadow and ethics), and to practice them concurrently. The aim of this paper is to encourage therapists to give pro-active attention to their self-system in order to ensure optimal functioning. Care informed by this view enables us to manifest the highest embodiment of presence, promotes our development as therapists, and exemplifies ethical service to all beings.

Much of our work as therapists is about encouraging clients to pay attention to the signals of their bodies, to develop awareness of their behaviours, emotions, thoughts, shadow, and to act in as much harmony with new perceptions as their level of development sustains. Encouraging clients to pay attention to indicators coming from their gross, subtle, and causal bodies facilitates horizontal as well as vertical integration. This comprehensive approach to working with clients necessitates modelling these behaviours in our own lives.

Three important questions for therapists to ask ourselves are: “Am I personally doing what I’m helping others to do? How am I attending to signals from all aspects of my being and life? Is vertical growth important to me personally?” The first of these questions occurred to me in embryonic form when I was a student of naturopathy in the late 1970’s, leading me to wonder whether I was actually living according to the holistic health principles about which I was learning. The insights from this question have continued to develop over the intervening years and today manifest as an ongoing process of attempting, as much as I humanly can, to practice what I preach. My current rationale for embracing an integral method of self-care is to model authenticity and to develop my capacities, not only as a therapist but also as a fully functioning human being. Using a variety of methods to attend to the messages to and from my body as well as the people and circumstances in my life, aids me in highlighting my shadow aspects, helps me develop ethical sensitivity, and generally contributes to an appropriate sense of responsibility in my life and work.

An Integral perspective on self-care entails understanding the three words inherent in an Integral Life Practice (ILP). Integral means comprehensive, balanced, inclusive; Life includes the whole of our existence, the body, our emotions, relationships, work, as well as the various levels of conscious awareness potentially available to experience; Practice is what we actually do to develop ourselves, which enhances our capacity to help and be of service to others, the actions we undertake to fulfil our potential. Therefore “…Integral Life Practice is a whole and balanced approach to practicing for life – our individual lives, the lives of others, even the life of the planet.”

I have chosen the current assortment of practices in my ILP to support me in the gradual expansion and development of balanced capacities for “care, compassion, and consciousness” so as to enhance awareness in all aspects of my professional and personal life. As therapists, we must remember that in periods of increased demands on our time and energy, it is harder to maintain a regular regime of self-care. Yet the more we engage in our ILP, the more we can draw on the reserves garnered through our established self-care programmes. I find it helpful to think of daily practice as building and maintaining a clear path to an infinite reservoir of energetic renewal , which is always available for me to access.

My interest in the area of therapist self-care arose for the following two reasons. First, it was not sufficiently addressed in any of the counseling and therapy trainings I’ve undergone. Where it was addressed, the two recommended approaches to self-care were supervision and personal therapy. The research shows these are necessary but not sufficient methods to ensure thriving in our line of work. This understanding necessitates that we transcend and include them in a much more comprehensive approach. Second, I’ve had a personal focus on de-stressing and healthy diversions to balance my work since my own brush with “compassion fatigue” in 1983, three years after I began working as a naturopath and counsellor. This was a shocking and debilitating experience for many reasons, including my own lack of understanding of what I was experiencing and compounded by the absence of support from my fellow workers and supervisors. With hindsight, I can now see that the combination of conditions leading to my compassion fatigue was an all quadrant affair. Having this integral perspective on fatigue informs my decision to apply an integral perspective to self-care. Since that time, I’ve maintained a comprehensive self-care regime which is flexible but consistent, constantly adjusting my ILP to my current life situation. The sentiment “Once bitten, twice shy” describes part of my motivation to persist throughout those times when resistance, in its many forms, creates obstructions in my practice path.

These two factors lead me to feel strongly about the necessity of keeping the issue of self-care in the awareness of all therapists, be they trainees or qualified therapists of any experience level. It is the critical factor in ensuring thriving and well-functioning in our work, which Coster & Schwebel refer to as the “…enduring quality in one’s professional functioning over time in the face of professional and personal stressors.” Thriving and well-functioning are not usually terms associated with counseling and therapy work. Yet research done on therapists who fulfill this description shows that they do exist. I’ve drawn extensively on the research of Coster & Schwebel, (1997 & 1998); Dlugos & Friedlander (2001); Norcross (2000); and Skovholt et al (2001) which reveals how thriving therapists maintain a healthy level of functioning, despite long-term exposure to their clients’ suffering. My search of the literature on burnout revealed five main points:

1) Psychological principles, methods and research are rarely applied to therapists themselves. 2) There is a great lack of systematic study on the self-care of the therapist. 3) Shame over being impaired by our work is common among affected therapists. This is unrealistic given the growing body of empirical research proving the negative consequences of a career in counseling , in addition to the well-documented frequency of compassion fatigue and vicarious traumatisation. 4) Prevention is far better than treatment, and studying those who have successfully managed years of working with distressed clients can be of vital assistance to all of us in the field. 5) Five common themes emerged in well-functioning therapists and their self-care methods, which I outline below.

A. Balance: Well functioning therapists consistently focused on balance in their lives; they established clear boundaries between work and personal life; they took regular vacations and utilised various stress reducing techniques; they practiced regular self-awareness/self-monitoring exercises and they possessed personal values which helped them observe ethical standards.

B. Diversity: Therapists sought diversity within work activities to maintain freshness such as conducting multiple forms of therapy; engaging in multiple activities in work; working with multiple types of clients and problems.

C. Robust selves: Their personalities were such that they tended to meet obstacles as challenges; they could embrace diverse theoretical orientations and had a continuing fascination with human development and change. Their values led to recognition that money was not the prime motivator for their work, as they were willing to pass up promotions in favour of a life less free of pressure.

D. Empathy to self: Research also clarified a sequence of steps that therapists took when they sensed their functioning was compromised. In summary, these consisted of admitting to themselves they were not coping, asking for help (from family, friends, colleagues and supervisors), pulling back on their work commitments, taking breaks when possible and focusing on relaxing and diverting activities.

E. Pro-active: Overall the research contradicted beliefs that well-functioning “just happens”. These thriving therapists were pro-active in their self-care. They sought out continuing education to diversify their work and to keep abreast of changes and they utilised support from peers, spouses, friends, mentors, therapists, and supervisors.

As Gilroy, Carroll & Murra emphasise , burnout is a given in therapeutic work. Therefore development of means to prevent it is imperative for sustained effectiveness as a therapist. Norcross’ findings suggest that possessing any one particular skill in one’s self-care programme is less important than having a variety of self-care methods. This supports the statement by Patten, Morelli, Leonard and Wilber , which encourages concurrently exercising various aspects of our being. They assert, “Cross-training is a key principle in ILP: your total capacities will develop faster and more effectively by engaging multiple practices rather than doing one or two in isolation.” These observations suggest that it would be helpful to regard burn-out, and its prevention, in an integral manner. An integral solution to enhance resilience and healthy functionality is comprehensive and requires an individualised ILP. The multi-faceted approach in ILP seems therefore to be an optimal method to ensure prevention of burnout and, in addition, to enhance the overall development of therapists’ potentials.

This paper will outline a comprehensive approach to promoting thriving for therapists by encouraging an integral approach to self-care. In summary, this comprises crafting a personalized ILP containing one or two practices from each of the five modules mentioned above. This pro-active and empathic attitude to the self enhances the factors ensuring buoyancy in our line of work. Factors such as balance, diversity, building more robust personalities, and focusing on the transcendent nature of therapy have proved to be far more essential components in maintaining well-being than supervision and engaging in personal therapy. As the self is the primary instrument used in our work, it is imperative that we honour it by treating it as an instrument worthy of pro-active attention paid to its quadrants, levels, lines, states, and types. Doing so ensures the maximum functionality and flexibility of the self, benefiting all beings with whom we come into contact.

Developmental Perspectives on Self-Care

Our concept of self evolves and develops through stages broadly known as prepersonal, personal and transpersonal. As therapists, our self identity determines what we perceive as being most salient to the maintenance of a healthy self. I view the group of practices utilised to take care of ourselves as being facilitators of growth along the various lines of development. These lines of development include (among others) cognition, affect, self-identity, morals, ideas of the good, needs, and empathy , with each line of development evolving quasi-independently of the others and influencing one or more of the three aspects of self discussed above. A developmental approach to self-care would also take into account the many facets of support we deem necessary to sustain us in the various aspects of our being such as the physical, emotional, mental, spiritual and interpersonal lines, as well as the cultural and social quadrants.

In looking at self-care as a function of development, the first, and “…arguably the most central line, to consider is the ego, or self line, of development. The self is the one who navigates the entire spiral of development, and our proximate self sense is determined by our center of gravity along this central line.” It is this self that we bring to our work, our relationships and our understanding of self-care and comprises, among other components, our physical body, our emotions, our cognitive capabilities, and our spiritual aspects.

Much work has been devoted to the development of the self as a function of self-awareness. I will be relating the separate aspects of the self to techniques within modules which we can apply in practicing a comprehensive self-care regime. First I’ll address the kinaesthetic aspect, which I refer to as the “body”, and define its gross, subtle, and causal aspects. Second is the cognitive aspect, referred to as “mind” in this paper. This aspect of our self contains the theoretical understanding or “view” we have regarding self-care. Cognition comprises the development of our perspective, and includes the sense and subtle perceptions, not only the logical or linear capacity for reasoning. Third, I address our spiritual aspect, referred to as the “spirit” module. Fourth, I attend to the psychodynamic practices for caretaking the unconscious aspects of our self, referred to as our “shadow”. The four aspects of body, mind, spirit, and shadow are four of the five most important modules to address in an AQAL approach to self-care. The other aspect which I believe to be of vital importance for us as therapists is that of “ethics”. This integrally informed perspective on self-care to promote thriving for therapists is, in essence, an Integral Life Practice (ILP) under another name.

Using the word “self” as described above helps to conceptualise it as the main instrument we engage in our work, life and relationships in general. Like any instrument, if it’s not kept in good working order, the negative results soon become apparent in these areas. What this means for us as therapists, is that it’s not simply what we know, but how we engage our work that is of vital importance. How we manifest in each moment has the most salient influence on the therapeutic relationship with our clients and the results of our work. “Research points to the existence of four factors common to all forms of therapy despite theoretical orientation (dynamic, cognitive, etc.), mode (individual, group, couples, family, etc.), dosage (frequency and number of sessions), or specialty (problem type, professional discipline, etc.). In order of their relative contribution to change, these elements include: (1) extratherapeutic [40%]; (2) relationship [30%]; (3) placebo, hope, and/or expectancy [15%]; and (4) structure, model, and/or technique [15%]”.

Since the extratherapeutic contributors to change in our clients are those factors that are part of the client (such as ego strength and other mechanisms) and part of the environment (such as fortuitous events and social support) that aid in recovery regardless of the participation in therapy , we must note that the next major factor enabling change in our clients is the relationship we have with them. An integrally informed approach to self-care for therapists begins with an understanding that looking after our selves is not something we engage when compassion fatigue becomes apparent. It makes a preventative and proactive approach a necessity. This begins with attending to the quadrants.

Quadrants The quadrants in an Integral approach to therapist self-care are a “primary tool” for conceptualising the perspectives which are present in any event. They represent the interior and exterior of individuals and groups. (See attached quadrant diagramme). In this paper I will be giving examples of practices which apply to each quadrant. Many of these practices impact multiple quadrants and lines contributing to multiple benefits. The recommendation in constructing an individualised ILP is to pick one or two practices from each of the five main modules. Norcross’ research on thriving therapists identified that they made self-care a priority and employed a range of different methods to ensure they maintained a healthy level of being. As a way of elaborating on this range of methods, I begin by relating the issue of self-care to the quadrants. I will explain in more detail the various self-care practices in the modules under the “Module Dynamics” section below. Using this range of methods facilitates a tetra-evolution in us which has ripple effects on all quadrants which co-arise and enable the co-evolution of the various lines, as well as the subtle and causal bodies .

Upper Right quadrant (UR)

The UR quadrant contains all the exterior, behavioural steps we can take to maintain our physical self. It is the realm of “What I do”. A good question to engage this quadrant is: “What are the most effective physical actions I can take regarding my own self-care?” This is the quadrant relating to objective truth.

On the gross physical level paying attention to a healthy diet features here. Some form of exercise is essential to balance the predominantly sedentary nature of our occupation. Honouring our individual requirements regarding the amount and quality of sleep which adequately nourishes us is also a factor in this quadrant, as is ensuring that we drink at least one and a half litres of pure water daily. Hobbies that give a genuine recharge belong in the UR, even though these also have significant social (LR) and cultural (LL) components. Finally, the various brain-mind technologies which induce alpha, theta, and delta brain waves with their corresponding states of consciousness (UL) belong in this quadrant. They are empirically tested means for enhancing functioning and well-being.

Research on well-functioning therapists clarified a sequence of behavioural steps when they sensed their functioning was compromised: they asked for help, they cut back on caseloads, and they sought to focus on relaxing, diversionary activities such as vacations and other stress-reducers.

Upper Left Quadrant (UL)

This is the unique, subjective interior within each of us therapists. It is the realm of “Why I do”. Here is where our intentions about self-care come to the fore when engaging with the questions “Why do I do what I do (or don’t do) about self-care?” and “What are my commitments regarding self-care?”

This is the quadrant related to subjective truthfulness. Self-awareness and self-monitoring about our own interiors, especially about our authentic needs, provides us with a wealth of valuable information about our levels of functioning and how that manifests in our worlds. The first step in caring for ourselves is attending to our own experience, valuing, and exploring what our interiors are communicating to our awareness. “Connecting with all parts of our experience – sensory data, thoughts, feelings, wants and actions…assists us in acting congruently on our self-awareness …and…generates personal energy, strength and health.” Self-awareness also requires paying attention to interpersonal feedback from significant others, and taking responsibility for our own reactions to this feedback.

The personal values which help us as practitioners to observe ethical standards of practice are mapped out in this quadrant. A value of honesty, for example, would entail the need to recognize the hazards of engaging in psychological practice as a profession: empirical research attests to the negative toll exacted by a career in therapy. The literature points to depression, mild anxiety, emotional exhaustion, and disrupted relationships as a common result of immersion in the inner worlds of distressed and distressing people.

In addition, the imperatives of confidentiality, the realities of isolation, and the shame felt when we experience the negative impact of our work lead us to overpersonalise our stress, when in fact they are a given in psychological work. It is essential, and indeed therapeutic, that we disconfirm our individual feelings of unique wretchedness and affirm the universal nature of the hazards in psychological work. To do so leads us to corrective action and informs our preventative measures. These preventative measures can be subdivided into three main lines of development in the UL quadrant, our mind, our spirit, and our shadow. I will address this in the section titled “Module Dynamics.”

Lower Left Quadrant (LL)

Here is the quadrant wherein we pay attention to our interior collective sense, our cultural internalizations, and how these are played out in relationships with others. This is the realm of “Why we do” and a fruitful question to hold in this area is: “What is my understanding of the impact on others of my self-care practices?” Giving and receiving support from peers, spouses, family, friends, mentors, therapists, and supervisors would be placed here. The focus of this quadrant, to paraphrase Landraitis is the awareness of how the relationships in which we are engaged are acting as instruments of healing, growth, and change, in ourselves, our clients, our partners, our families, our communities, and ultimately, in all sentient beings. It is here that we hold the awareness of and actively engage in practices (both while at work and in our everyday lives) of making relationships part of our growth.

Decentring our selves in relationship comes into play in this quadrant. This is expressed via our understanding of the moral obligations of self-care and how this relates to compassion for Self in interaction with and relation to all sentient beings. Compassion for others can take the form of providing rebated services to clients in genuine need, engaging in community service, volunteer work, hospice work, or meditative practices such as tonglen. It can also refer to the applied moral values in how we view our work and exercise “therapeutic presence”

Lower Right Quadrant (LR)

This is the quadrant where we map the exterior collectives to which we as therapists belong. It can be paraphrased as inter-objective, functional fit. Useful questions to contemplate in regard to this quadrant are “How do we do things together?” and “What is my function in the over-all system of self-care.” The various social systems and communities with which we are enmeshed consist of our intimate relationships, families and friends, our peer, supervision, training, and professional conference networks, as well as any outreach activities in which we may be involved. Well-functioning in this quadrant has been shown to be enhanced by focusing on diversity and synergy of professional activities such as: conducting multiple forms of therapy (individual, couples, group); engaging in a range of activities (e.g. therapy, assessment, research, teaching, supervision, consultation); as well as working with a variety of clients and problems (age, ethnicity, different types of disorders).

On an institutional level, this quadrant takes into account the professional, educational, and political networks in which we are involved. In addition, it is where we map our civic duties to family, town, state, nation, and the wider world. It’s important to note that current policies in relation to distressed and impaired practitioners tend to be inconsistent and incomplete, and focus on code enforcement rather than on prevention efforts.

Gilroy, Carroll & Murra claim that the key to burnout prevention lies in the establishment of a professional ethos in which self-care is viewed as a moral imperative. They suggest that at a systemic level, guidelines for practicing self-care must be incorporated within professional codes of ethics. They also recommend the provision of continuing education credits for participation in a variety of self-care activities, such as personal therapy, peer supervision, meditation, and other such activities. At the institutional level, they argue that the current focus in universities and professional schools of therapy on clinical skills is insufficient. They stress that personal psychotherapy must be mandated, and that “…more attention is needed in terms of self-care and education concerning possible risk factors associated with such problems as compassion fatigue, distress, and impairment”. They point out that those who are introduced to self-care and personal therapy early in their professional lives are more likely to undertake such means continually throughout their careers.

Finally they assert that “It is important that such self-care action plans be comprehensive in nature and include attention to the physical, cognitive, emotional, recreational, and spiritual dimensions”. Dlugos and Friedlander suggest that for the field to retain motivated, competent professionals training and education programmes need to emphasise balance, integration of work with the rest of life, and the spiritual and transcendent nature of therapy. Applying an AQAL perspective in our work and self-care practices exceeds these recommendations.

Module Dynamics

The focus in this section will be on five key modules to be addressed in an AQAL approach to therapist self-care. Each module will be discussed separately, but will simultaneously incorporate (as appropriate) the levels of development which each undergoes. The four core modules of an Integral approach to therapist self-care are body, mind, spirit and shadow. I have added one other module to the cadre of “official” modules of Integral Life Practice, which I regard as key to a balanced self-care approach – the module of ethics.

Body (Physical, Subtle, Causal)

The three levels of body for which we need to care are our physical, subtle and causal bodies. The physical body is composed of muscles, bones, organs and biochemical elements. Acknowledging my naturopathic bias, I’ll begin with suggesting that we pay attention to our diet. The overall aim is towards balancing the macro nutrients (lean proteins, complex carbohydrates, and cold-pressed fats, including monounsaturated fats and deep sea fish oils) and the micro nutrients (vitamins, minerals, and hormones). The inclusion of a large portion of fibrous carbohydrates, in the form of fresh vegetables and fruit is found to be essential for the maintenance of an appropriate level of alkalinity in the body. Some of the literature on naturopathic nutrition suggests that an overly acidic blood pH is highly contributive to the development and maintenance of many disease processes. The ratio of acid to alkaline, as well as the balance of the macro and micronutrients will be unique for each therapist, and needs to be continually adjusted to account for differences in gender, age, personality, body type (endomorph, mesomorph, ectomorph – as one way of differentiating body typology), any existing health problems, in addition to the level of physical activity we undertake.

The second focal area for the gross physical body is exercise. The overall recommendations here are not only to increase our cardiovascular capacity (through various activities like aerobics, sport, brisk walking, swimming, dancing and so forth), but also to strengthen our physical mass (through weight-lifting) and maintain suppleness (through practices such as yoga or stretching). As previously mentioned, the sedentary occupation of therapy often leaves a great imbalance in this area. In addition, attention needs to be drawn to the length of our working hours which may impinge on getting quality sleep and physiological rest time.

With respect to the neurological system in the gross physical body, pharmacological means of restoring or maintaining balance may at times be required. This can be achieved by allopathic or holistic medical means, via prescription medication, herbs, vitamins, minerals, and hormonal supplements. While we as therapists are skilful in encouraging our clients to take medication, we may feel ashamed when they may be needed for ourselves. It is a useful reminder that massage, acupuncture, shiatsu, kinesiology, chiropractic, and osteopathic treatment methods (among others) address neurological balance on the gross as well as the subtle body levels.

Our subtle body is made up of the energetic aspects of our being, variously called breath, prana, chi, life-force, and energy-flow. Our emotions and mental functions are supported by this body. Caring for our subtle bodies constitutes utilising practices such as Hatha Yoga, breathing exercises, Tai Chi Chuan and Qi Gong (among others) which may be incorporated to promote a healthy energy flow throughout the body. As therapists it also involves developing awareness during therapy of the quality and rate of our breath, as well as to the subtle emotional and cognitive fluctuations indicative of these breath changes.

Our causal body comprises the infinitely extending field of awareness of all of existence. It has been labelled in various ways, describing such qualities as presence, openness, spaciousness, feeling inwards or outwards to infinity. Causal energy deals with the very rarest of energies and is “…often experienced as the infinite field energy surrounding and radiating from the self. The causal body is called “causal” because it is the cause and support of the other bodies. Causal body exercises are fairly rare and hard to find.” Practices which care for this aspect of our being include certain formless meditation practices as well as the 3-Body Workout or “Integral Kata” set out in the Integral Life Practice Kit.

Mind (Framework, View, Perspective)

The mind module involves developing an orienting framework or cognisance of the many possible perspectives related to our work as therapists. The terms cognition and consciousness are used synonymously here, and their levels of development span from subconscious/prepersonal to self-conscious/personal to superconscious/transpersonal and include interior as well as exterior modes of awareness. The AQAL framework provides a clear overview of the basic dimensions of our being-in-the-world, and supplies pointers on how to maintain mindfulness of these perspectives whilst engaged in working. This Integral theoretical framework for the “Mind” module of ILP embraces many perspectives, including relational-developmental views of therapy, intersubjectivity theory, and dialogical approaches. The interrelationship of these to self-care provides a way of understanding the reciprocal influences of client and therapist on each other and how both healing and dysfunction can result from the encounter between two people.

Developing a stable multi-level sense of ourselves enables us to be present in as comprehensive a way as possible. When we as therapists can make our own complexity an object of our awareness, whilst also being cognizant that there are forces operating within the many levels of our consciousness, this gives us the capacity to create more comprehensive maps to embrace and guide our insights. This in turn sets the framework and holding environment for a corresponding development of a secure self-sense in our clients because we can now present a much more embodied resonance with the levels present in our clients.

Being cognisant of the spectrum of consciousness available to us whilst holding a concurrent awareness of these same levels in our clients, allows us to embrace a much wider perspective about what needs care and attention in the intersubjective space. An understanding of the importance of a fully-embodied “presence” in our work with clients, is beautifully expressed by Pearson. She says:

“Therapeutic presence, the embodiment of integral awareness, is at the core of any truly integral psychotherapy. It is the basis for empathic attunement with our clients…Simply stated, therapeutic presence requires that we track what is happening within us as the clinician, what is happening in the client, and what is happening between the two of us, drawing on both subjective and objective methods (the unified basis of integral assessment). This simultaneous tracking of awareness calls upon what we think, what we dis/identify with, what we sense, what we feel, what we encounter and what we recognize.”

Self-care practices which attend to the gross, subtle, and causal aspects of the body, emotions, mind, and spirit enhance development of the capacity for an embodied and centered therapeutic presence.

Other means of fostering our ongoing development in the mind module are continuing education and keeping abreast of changes in our fields of interest. Further useful practices are those which clarify our vision about our philosophy of life, in the broad sense, and ourselves as practitioners, in the more focused sense. Techniques such as visualisation and affirmation may also be included in the mind module.

It is important for us as therapists to be aware that the very nature of our work transforms us as people and holds within it the capacity to foster our own development. How this occurs, at least in the developmental lines of cognition, affect and self-sense, is eloquently expressed by Ingersoll, who says: “An Integral approach to ‘doing’ psychology is itself a vehicle for the transformation of the psychologist…to an information broker capable of synthesizing diverse findings across the specializations of psychology and from fields outside of psychology….This allows us to explore new questions that could not be asked until now. To ask the questions, however, requires that we transcend parochial boundaries.”

I suggest that this also applies to transcending the boundaries which have limited our understanding of the need to apply a variety of self-care practices which take into account quadrants, lines, levels, states, and types. Doing so will facilitate optimal functioning and development in your work.

Spirit (Meditation, Prayer, Stillness)

The literature on thriving therapists states that training and education programmes that emphasise balance, integration of work with the rest of life, and the spiritual and transcendent nature of therapy may be essential for the field to retain motivated, competent professionals. Research by Dlugos & Friedlander showed that “passionately committed psychotherapists” experience a strong sense of spirituality. Regular and consistent practice of spiritual disciplines inherent in any established spiritual tradition facilitates a “direct experience of the sacred,” which is the third of Wilber’s definitions of spirituality. Dlugos & Friedlander found that an interest in activities unrelated to work as therapists, and attention to spiritual disciplines and development were as crucial, if not more crucial, than the pursuit of professional avenues of achievement to maintain well-functioning.

A broad range of spiritual practices is now readily accessible to those interested in this endeavour. These include shamanic practices, contemplative or centring prayer, Vipassana, Zen, Dzogchen, and other so-called “Witnessing” meditations. Research on the effects of regular meditation attest that it leads to the following benefits:

• provision of meaning frameworks for the human condition
• beneficial effects on the physical, emotional, mental and spiritual aspects of being
• provision of social support networks and relationships
• clarification and development of personal values
• enhancement of self-awareness and self-monitoring capacities
• heightening of altruistic motivations coupled with capacities to act on these in a realistic manner. Using the self-awareness gained via meditation is particularly important as a means of assessing whether we are altruistically extending ourselves beyond our capacities.

Shadow (Fixations, Subpersonalities, Projections)

Attending to our own shadow work by using techniques to expose, interact with and eventually re-own diverse aspects of ourselves is an essential component of an ILP for therapists. It is often the disowned parts of ourselves, residing in the prepersonal, personal, or transpersonal aspects of our being, which disrupt our ability to maintain a healthy functionality in our personal and professional lives. The word “shadow” is often misunderstood as referring only to the negative aspects of our unconscious or preconscious selves. It is useful to note that the disowned (or not yet manifest) aspects of our antecedent self, which contains our best parts, may also be accessed by shadow work. Both our lower and higher self can be concealed in the shadow. Dealing with shadow aspects assists us in shifting perspective on the parts of ourselves which we unconsciously repress or deny, and which therefore interfere with our optimal functioning and development as therapists. For these reasons, working with our shadow is a key ingredient of ethically responsible self-care.

The literature on well-functioning therapists suggests that supervision and returning to our own personal therapy are necessary but not sufficient means to ensure that we thrive in our line of work. In addition to these indispensable methods, there are many practices which can be done on our own and which are highly effective in helping us identify and then integrate the disowned parts of our selves. These include dream work, journaling, dialoguing, drawing and the 3-2-1 process

The 3-2-1 process may be applied to any strong physical, emotional, mental, or spiritual reaction, and is summarised as “3-Face It, 2-Talk to It, 1-Be It”. In “Facing It”, we describe the object of our awareness in great detail using 3rd person pronouns (such as it, its, she, her, him, his, they or theirs), as a way of fully exploring that which initiated the disturbance. In “Talking to It”, we dialogue with the person, image, or sensation using 2nd person pronouns (like you or yours), as a way of entering into some sort of relationship with it and bringing it one step closer to ourselves. We then give this object a voice and allow it to speak back to us, in response to any questions or comments we have made to it. In “Being It”, we write or speak using 1st person pronouns (such as I, me or mine), integrating this person, object or sensation back into ourselves as a way of re-owning it and re-identifying with it. We see ourselves and the world from the perspective of that disturbance, discovering our commonalities and seeing that we are substantially the same being. We can end the process by making a statement such as “I am…” or “…is me”. Once we’re familiar with using this process to care for ourselves, it can be accomplished in one to two minutes and is particularly useful for any counter-transference disturbance.

Ethics (What We Do. How You Act! Why Should I?)

This developmental module deals with our self-discipline, our personal and professional codes of conduct and our different social and ecological levels of activism as well as any vows or oaths we have undertaken. The Oxford Compact English Dictionary defines ethics as “the branch of knowledge concerned with moral principles” as well as “the moral principles governing or influencing conduct”. In this section, I will be using the terms “ethics” and “morals” interchangeably. Wilber proposes that the Basic Moral Intuition (BMI), which is present at all stages of human growth, is to “protect and promote the greatest depth for the greatest span.” Depth and span are defined in different ways dependent upon the level of growth in this module. He argues that this is a direct result of Spirit manifesting in the four quadrants, with an increasing growth in depth/height in the “I” expanding to include others in a “We” in a correspondingly broader/wider objective state of affairs manifesting as the “It”. He further claims that the BMI will have a different definition of self, others, and objects at different levels of development.

The moral imperative towards self-care in our professional ethos, urged on us by Gilroy, Carroll and Murra, is viewed in various ways at different levels of development. At the egocentric/preconventional level, the moral stance towards self-care focuses only on the individual self of the therapist, solely promoting and protecting herself or himself. My belief is that a small minority of therapists are at this stage of moral development. Pathological behaviours typical of this level would indicate that they are distressed or impaired practitioners, and would most likely take the form of predatory use of their authority over clients for financial, sexual, or other gains.

At the sociocentric/conventional level of moral development, a therapist acknowledges the existence of depth in others, but perhaps regards self-care in line with the duty ethic, something to be undertaken as another in a long line of self-defining “shoulds.” Perhaps self-care is encouraged solely within their own therapeutic culture, to protect and promote this culture ahead of others. In addition, exploration outside the cultural norms of self-care within their particular school of therapy would not be supported.

At the worldcentric/postconventional level, therapists begin to understand the need to be flexible in their own methods of self-care, drawing on broad principles which promote health and well-being in all humans. Depth is extended to all therapists, change agents, or those working in fields promoting wellness, and span here includes all human beings. At this level of ethical development, therapists design a personal self-care regime embracing the four quadrants. There is awareness and corresponding action taken to address issues in physiology and behaviour (UR), thoughts, feelings, and identity as therapists and human beings (UL), cultural values (LL), and social relations (LR), although depth in these quadrants may be undifferentiated to account for increasing levels of complexity.

At the transpersonal/ post-postconventional levels of morality, the BMI according to Wilber would be conceived of as encompassing the Buddha (I), Dharma (It), and Sangha (We), with the ultimate Sangha being the community of all sentient beings. Self-care practices here embrace and are an expression of care, compassion, and concern towards all beings. At this level self-care includes a vital awareness of and presence to Spirit’s eternal descent through soul down to matter, as well as its endless ascent from matter to body, mind, soul, spirit, reuniting once more to Spirit. At this level of moral development, self-care is a desire to protect and promote Spirit in the individual self of the therapist as well as in all sentient beings and exists alongside a sense of responsibility to somehow facilitate this unfolding in all beings. The very process of manifestation and destruction, as something that is unequally applied, also becomes part and parcel of the Basic Moral Intuition for ethics at this level.

The specific details of how to implement this BMI are part of the “…intersubjective and cultural and social project that all of us, in open communication free of domination, must discuss and decide. That is why the human moral response is a fine mixture of the Divine and the Human”. One possible implementation at this level would be that of viewing the self of the therapist as the primary instrument used to carry out this BMI. A post-postconventional moral perspective would see self-care as a responsibility to keep this instrument as finely tuned as possible so as to bring the best “self-system” to the Kosmos. This is an expression of morality utilising Universal-Spiritual principles in which “…universality and relativity are applied where necessary…this moral position begins to include even non-human creatures as part of the overall expression of moral value.” The drive behind this level of self-care springs from a core value of wishing to contribute to life in all its forms and is coupled with an incapability of carelessly behaving in egocentric ways. This perspective is seen as a responsibility, a calling to express in the fullest, deepest way so as to be of benefit to all sentient beings.

States

This aspect of AQAL theory, which draws on the great wisdom traditions of the world’s cultures, refers to the states of consciousness which are available to sentient beings at all times. Although Vedanta (Hindu philosophy) gives five natural states of consciousness, known as waking, dreaming, deep sleep, Witnessing, and Nondual, for the sake of simplicity I will address only the three states of waking, dreaming, and deep sleep. State experiences include:

• the ordinary or waking states
• nonordinary or trance states. These states of consciousness include:

1) exogenous states (drug induced) 2) endogenous states (dream states, hypnotic or other trance states, visualisation and the trained states of consciousness such as those brought about by meditation).

• peak experiences, the heightened states of consciousness, which can be spontaneous or induced through drugs, exercise, trauma, sexual activity, or meditation practices.

Each of the three major natural states of consciousness (waking, dreaming and sleeping), according to Wilber are said to be supported by a particular energy or “body,” the gross body, the subtle body, and the causal body.

“Although, technically speaking, the terms ‘gross,’ ‘subtle,’ and ‘causal’ refer only to the bodies or energies (in the UR), we also use those terms to refer to the corresponding states of consciousness (in the UL). Thus we can refer to … natural, and/or meditative states of consciousness as: gross, subtle, causal… states…”

The AQAL map, drawing on the cartography of the wisdom traditions, gives therapists a large toolbox from which to draw self-care practices with the potential to lead to phenomenological experiences of these various states. In addition, “…the Integral approach to states and their relation to levels and lines of development help…understand… experiences in a way unique to any approach to psychotherapy.”

Drawing on Wilber’s suggestions, practices which are linked to and may bring about state experiences at the different levels, are: 1. For gross-waking states: Focusing on the physical body and its surroundings during any activity, such as in a therapy session or whilst doing physical exercise. 2. For subtle-dream states: Paying attention to our dreams or daydreams. Visualisations feature here, as do meditations with form (focusing on breath, mantra, image), as well as any practices which focus and direct our awareness to subtle images and sensations, such as those occurring during or about a therapeutic session. For causal-formless states, such as those in deep dreamless sleep, formless meditation and experiences of openness or emptiness. These occur during the Big Mind/Heart practice or with mind/brain technologies. They can also be accessed by opening to the vast causal space in the pauses between client and therapist interactions or by taking a few moments before each session to engage in a silent prayer or dedication.

Generally state experiences can only be consciously induced through regular, daily prayer, contemplation or meditation practices which develop a capacity to enter subtle and causal states at will. This is achieved by focusing attention in a consistent manner so as to bring about trained states which tend to unfold in a sequential order, from gross to subtle to causal. These states can be experienced at any level of self development, are included in horizontal integration and are labelled by Wilber as state-stages . They do not necessarily indicate the permanent attainment of a higher stage of development in any of the lines of intelligence which are called structure-stages , indicative of vertical integration.

Types

Understanding the role of typology is useful in developing a self-care programme. The most common typologies in use are those which differentiate masculine and feminine (biology and identity), the Myers-Briggs Type Inventory, the Enneagram , as well as personality theory, using either the psychodynamic, trait, humanistic, or cognitive-social methods of personality assessment. According to AQAL theory, and with the exception of some Enneagram authors, these are all “horizontal typologies” in that they do not take into account the various levels of development but rather provide an understanding of the diversity of enduring personality orientations throughout the differing levels of complexity.

Therapists of different typologies inevitably choose and pursue different methods to care for themselves, varying these according to their level of development in the self-related lines and adapting these to their current circumstances. For example, an Enneagram type 3 may be at Loevinger/Cook-Greuter’s Conforminst, Conscientious, Individualistic, Autonomous or Integrated levels of self-identity development. These divergent orientations would influence the practices chosen to maintain health and balance, as well as those practices deemed most helpful in bringing about the desired changes.

A core value of success is found in many Type 3’s. At the Conscientious level, for example, this may manifest as self-care practices involving competitive sports which would involve applying themselves to training according to the dictates of their particular team’s ethos. In contrast, a Type 3 at the Integrated level, because they are free of the belief that their value depends on others’ positive regard, and via alternative means of expressing their value of success, may devote themselves to contemplative practices which help them discover their true identity and their own deepest wishes . Typology is another lens through which to view aspects of the self of the therapist, make them objects of awareness thus enabling these aspects to be transcended and included in a balanced self-care regime.

This paper has endeavored to show that self-care practices which attend to the gross, subtle and causal aspects of body, mind, and spirit as they occur in the four quadrants enhance the development of the therapist and make for a resilient, embodied, and centered therapeutic presence. The literature on thriving therapists quoted in this paper shows that therapist fatigue is best prevented by an integral approach addressing all quadrants, levels, lines, states, and types. Although the individualized self-care regimes mentioned were not undertaken through an understanding informed by an integral theoretical framework, they nevertheless covered the important elements of an AQAL approach.

In particular, their embracing of the transcendent and spiritual nature of therapeutic work resulted in enhanced resilience in the face of clients’ distress, in harmonious development in the therapists’ self-related lines and in a deeper experience of the complexity and interconnectedness of the self. An Integral Life Practice embodies that more complete view of the self, the primary instrument used in our work, and provides the means for its ongoing proactive care and maintenance to ensure our resilient, optimum functioning. It enables the highest calibre of presence to emerge in all aspects of our being, which benefits not only our personal self, but also our manifest Self in the form of our clients, family, friends, communities, and eventually the entire Kosmos. Applying an integral perspective to self-care is a means of being of service to all in a profoundly ethical way.

ENDNOTES

AQAL is an abbreviation for all-quadrants, all-levels, all-lines, all-states, all-types. The quadrants are the four dimensions inherent in any occasion, the interior and exterior of an individual or collective. Levels refers to levels or stages of development, such as egocentric/preconventional, ethnocentric/conventional, and worldcentric/postconventional. Lines is an abbreviation of the various intelligences available to humans, such as cognitive, emotional, kinaesthetic, moral, psychosexual and so forth. States refers to the major states of consciousness experienced by all, such as waking, dreaming and deep sleep. Types are typologies which can be present at any stage, such as masculine and feminine, Myers Briggs, the Enneagram, Keirsey Temperament sorter etc. For a short description see Wilber, A theory of everything, 2001, pp. 52-55). All of these terms will be elaborated on in the main body of this paper.

ILP stands for Integral Life Practice which Wilber in One taste, 2000, p. 123, defines as “… ‘all-level, all-quadrant.’ In short, exercise body, mind, soul, and spirit in self, culture, and nature. ‘Body, mind, soul, and spirit’ are the levels; and ‘self, culture, and nature’ are the quadrants (or simply the Big Three of I, we, and it). The more categories engaged, the more effective they all become (because they are all intimately related as aspects of your own being.)”

Here I’d like to define my use of the word “self”. I use “self” as a broad and complex term for the entity to which we’ll be applying the various self-care methods to be discussed. “Self” refers simultaneously to our “proximate self” (our subjective experience referred to in first person), our “distal” self (subjective aspects which have become objects of our awareness, referred to in third person) and to the “antecedent self” – which is the witness of all subjects, objects and processes involved. (See Ingersoll & Cook-Greuter, in press.) It is the totality of this “self” that we bring to our second-person interactions with others.

There are at least four meanings given to the words “spirit” and “spiritual”, briefly summarised as: 1. the highest level in any of the developmental lines; 2. a separate developmental line in itself; 3. an extraordinary state or peak experience which can happen at any stage of development; 4. an attitude or state of consciousness (such as love, compassion or wisdom) which can be present at any stage of development. See Wilber, “What is integral spirituality?”, 2005, pp. 63-64.

Shadow refers to the unconscious positive and negative aspects of our awareness.

Ideally, an integrally informed therapist aims to “… integrate both the Ascending movement (from body to mind to soul to spirit) and the Descending movement (from spirit to soul to mind to body).” Wilber, One taste, 2000, p. 205.

“Horizontal integration basically involves an integration of the four quadrants at any given level…Vertical integration, on the other hand, means moving to a higher level of integration altogether…each level of development has the capacity to be relatively more integrative than its predecessors, simply because each healthy level “transcends and includes,” and thus each senior level can embrace more holons in its own being and thus is relatively more integral.” (Wilber, A theory of everything, 2001, p. 152).

A holon is a whole that exists in other wholes, so they are whole/parts.

Morelli, Leonard, Patten, Salzman & Wilber, Welcome to integral life practice, 2005 p. 6.

Wilber, “Kosmic consciousness”, 2003.

The antakharana, according to Theosophy is “…the bridge that man builds – through meditation, understanding, and the magical creative work of the soul – between the three aspects of the mind nature…Before a man can tread the Path he must become the Path himself…The antakharana…is the thread of consciousness, of intelligence, and the responsive agent in all sentient reactions.” Bailey, Ponder on this, 1971, pp.17-19. For the three aspects of the mind nature, see Note 15 concerning subtle body.

Coster &Schwebel 1997, 1998; Dlugos & Friedlander 2001; Norcross 2000; Skovholt et al 1997, 2001.

Figley, Compassion fatigue – coping with secondary stress disorder in those who treat the traumatized, 1995, uses the term “compassion fatigue” interchangeably with the term “secondary traumatic stress”. Secondary traumatic stress is distinguished from burnout by its rapid onset and the extent to which the ailing therapist presents with similar symptoms to those affected by post traumatic stress disorder.

Coster and Schwebel, “Well-functioning in professional psychologists”, 1997.

Norcross, “Psychotherapist self-care: Practitioner-tested, research-informed strategies”, 2000, p. 2.

Gilroy, Carroll & Murra, “A preliminary survey of counseling psychologists’ personal experiences with depression and treatment”, 2002.

Norcross, “Psychotherapist self-care: Practitioner-tested, research-informed strategies”, 2000.

Patten, Morelli, Leonard and Wilber, My ILP handbook: Getting started with integral life practice, 2005, p81.

Dlugos & Friedlander, 2001, p301.

See Wilber, Integral psychology: Consciousness, spirit, psychology, therapy, 2000, p. 28.

“Evidence shows that a person, in the same act and absolutely simultaneously, can be at one level of cognition, another level of self-sense, and yet another level of morals, which cannot be explained by models like SD that draw primarily on one line.” Wilber, What is integral spirituality?, 2005, p. 28). SD refers here to Spiral Dynamics.

Pearson, “The development of desire”, 2005, p. 16.

Patten, Morelli, Leonard, Wilber, 2005, p.9.

Miller & Duncan, “What works in therapy”, 2005.

Hubble, Duncan Miller, The heart and soul of change – what works in therapy, 2003, p. 33

Ingersoll & Cook-Greuter, in press.

Norcross, “Psychotherapist self-care: Practitioner-tested, research-informed strategies”, 2000.

“…events…all arise simultaneously in AQAL space and tetra-evolve in mutual mesh. Neither things nor relationships are prior: both are simply different perspectives or dimensions of the AQAL matrix.” (Wilber, Excerpt A, Part 2, p. 9)

See Harris’ “Thresholds of the Mind”, 2002.

Miller, Miller, Nunnally & Wackman, “Talking and listening together”, 1992, p. 11.

Norcross, “Psychotherapist self-care: Practitioner-tested, research-informed strategies”, 2000.

Brady, Healy et al 1995, cited in Norcross 2000.

See Figley, 1995; Gilroy, Carol & Murra, 2002; Skovholt, Grier & Hanson, 2001; Norcross, 2000.

Norcross, ibid, 2000.

Landraitis, “Depression, identity, and intimacy in young adulthood”, 2005, p. 24.

The Self can be seen as “…an intuition of the very Divine as one’s very Self, common in and to all peoples (in fact, all sentient beings)…” Wilber, Sex, ecology, spirituality: The spirit of evolution, 2000, p. 239.

Tonglen is a Tibetan meditation of taking compassion for ourselves and then sending it to others, so as to experience the interconnection of all of life. “What you do for yourself – any gesture of kindness, any gesture of gentleness, any gesture of honesty and clear seeing toward yourself – will affect how you experience your world. In fact, it will transform how you experience the world. What you do for yourself, you’re doing for others, and what you do for others, you’re doing for yourself.” Chodron, Start Where You Are, 1994, p.33.

Pearson, “Integral practice for psychotherapists: Therapeutic presencing – awakening the heart of compassion”, 2005, p.1.

Skovholt et al 1997, 2001.

O’Connor 2001, cited in Gilroy, Carroll & Murra, “A preliminary survey of counseling psychologists’ personal experiences with depression and treatment”, 2002.

Gilroy, Carroll & Murra, “A preliminary survey of counseling psychologists’ personal experiences with depression and treatment”, 2002.

Ibid.

Pope & Tabachnick, 1994 cited in Gilroy, Carroll & Murra, 2002.

Carroll et al. 1999, cited in Gilroy, Carroll & Murra, 2002.

Dlugos & Friedlander, “Passionately committed psychotherapists: A qualitative study of their experiences”, 2001.

“Body” in AQAL theory is used to denote the “…energetic support of the various states and levels of mind, of which Vedanta (Hindu philosophy) gives three: the gross body of the waking state (which supports the material mind); the subtle body of the sleeping state (which supports the emotional, mental and higher mental levels); and the causal body of deep sleep (which supports the spiritual mind).” Wilber, Integral psychology: Consciousness, spirit, psychology, therapy, 2000, pp. 12-13.

See Diamond, H & M Fit For Life: Living Health, 1987, pp.86-87 and Spong & Peterson, Food Combining, 1990, pp44-50.

Morelli, Leonard, Patten, Salzman & Wilber, Welcome to integral life practice, 2005, p. 16.

ibid

Wilber, Integral psychology: Consciousness, spirit, psychology, therapy, 2000, p. 20.

Pearson, “Integral practice for psychotherapists: Therapeutic presencing – awakening the heart of compassion”, 2005, p. 2.

Ingersoll, “An introduction to integral psychology”, 2005, p. 13.

Dlugos & Friedlander, “Passionately committed psychotherapists: A qualitative study of their experiences”, 2001.

Walsh, Essential spirituality,1999, p. 3,

Wilber, Integral psychology: Consciousness, spirit, psychology, therapy, 2000.

Dlugos & Friedlander, “Passionately committed psychotherapists: A qualitative study of their experiences”, 2001.

See Vaughan, The inward arc: Healing in psychotherapy & spirituality, 1995 plus Shadows of the sacred – Seeing through spiritual illusions,1995; Walsh & Vaughan, Paths beyond ego: The transpersonal vision, 1993; Wilber, Engler & Brown, Transformations of consciousness: Conventional and contemplative perspectives on development, 1986.

Patten, Morelli, Leonard & Wilber, My ILP handbook: Getting started with integral life practice, 2005, p73.

Patten, Morelli, Leonard & Wilber, My ILP handbook: Getting started with integral life practice, 2005, p73.

Ibid p.75.

Soanes, (Ed) The Oxford Compact English Dictionary (2nd ed), 2000.

Wilber, Sex, ecology, spirituality: The spirit of evolution, 2000, p. 640.

Gilroy, Carroll & Murra, “A preliminary survey of counseling psychologists’ personal experiences with depression and treatment”, 2002.

Pearson, “The development of desire”, 2005, p. 14.

Wilber, Sex, ecology, spirituality: The spirit of evolution, 2000, p. 641.

Spiritual community.

Wilber, Sex, ecology, spirituality: The spirit of evolution, 2000, p. 761.

The original meaning of Kosmos, introduced by Pythagoreans, was “…the patterned nature or process of all domains of existence…not merely the physical universe…Kosmos contains the cosmos (or the physiosphere), the bios (or biosphere), nous (the noosphere), and theos (the theosphere or divine domain) – none of them being foundational (even spirit shades into Emptiness). Wilber, Sex, ecology, spirituality: The spirit of evolution, 2000, p. 45.

Zeitler, D. Integral Psychotherapy – An AQAL Approach to Transformation, p.19.

Wilber, What is integral spirituality?, 2005, p. 37

Ibid, p. 38.

Ibid, (ibid, pp. 38-39).

Ingersoll & Cook-Greuter, in press.

Wilber, What is integral spirituality?, 2005, p. 39.

Wilber, What is Integral spirituality?

Wilber, Integral Spirituality, 2006, p.76.

Ibid, p.76.

Ibid, p.76.

Riso & Hudson, The Wisdom of the Enneagram, 1999.

Wilber, Integral psychology: Consciousness, spirit, psychology, therapy, 2000, p. 53.

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