Anxiety, Stress, & Coping
An International Journal

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/gasc20

Associations between self-care practices andpsychological adjustment of mental healthprofessionals: a two-wave cross-lagged analysis
Pascale Brillon, Michelle Dewar, Alison Paradis & Frederick Philippe
To cite this article: Pascale Brillon, Michelle Dewar, Alison Paradis & Frederick Philippe (2023)
Associations between self-care practices and psychological adjustment of mental healthprofessionals: a two-wave cross-lagged analysis, Anxiety, Stress, & Coping, 36:5, 603-617, DOI:
10.1080/10615806.2023.2178646
To link to this article: https://doi.org/10.1080/10615806.2023.2178646

View supplementary material

Published online: 15 Feb 2023.

Submit your article to this journal

Article views: 577

View related articles

View Crossmark data

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=gasc20

ANXIETY, STRESS, & COPING
2023, VOL. 36, NO. 5, 603–617
https://doi.org/10.1080/10615806.2023.2178646

Associations between self-care practices and psychologicaladjustment of mental health professionals: a two-wave crosslagged analysis
Pascale Brillon, Michelle Dewar, Alison Paradis

and Frederick Philippe

Psychology Department, Université du Québec à Montréal, Montréal, Canada
ABSTRACTARTICLE HISTORY

Cultivation of self-care is believed to foster more well-being and to
mitigate the psychological diﬃculties that mental health professionals
experience. However, how the well-being and psychological distress ofthese professionals impact their personal self-care practice is rarely
discussed. In fact, studies have yet to investigate whether the use of
self-care improves mental health, or whether being in a better place
psychologically makes professionals more prone to using self-care (orboth). The present study aims to clarify the longitudinal associations
between self-care practices and ﬁve indicators of psychologicaladjustment (well-being, posttraumatic growth, anxiety, depression, andcompassion fatigue). A sample of 358 mental health professionals wereassessed twice (within a 10-month interval). A cross-lagged model
tested all associations between self-care and psychological adjustment
indicators. Results showed that self-care at T1 predicted increases inwell-being and in post-traumatic growth, and a reduction in anxiety
and depression at T2. However, only anxiety at T1 signiﬁcantly
predicted greater self-care at T2. No signiﬁcant cross-lagged
associations were found between self-care and compassion fatigue.
Overall, ﬁndings suggest that implementing self-care is a good way formental health workers to “take care of themselves.” However, more
research is needed to understand what leads these workers to use selfcare.

Received 5 November 2022
Revised 2 February 2023
Accepted 5 February 2023
KEYWORDS

Self-care; mental healthprofessionals; well-being;
distress; cross-lagged model;
psychological adjustment

Mental health professionals, such as psychologists, social workers, psychosocial counselors, mental
health nurses and psychiatrists play a key role in providing care and support in their communities.
The critical importance of their work has been made even more obvious in the face of the COVID-19
pandemic. The unrelenting distress, which has emerged or worsened in response to this pandemic(see a systematic review by Vindegaard & Benros, 2020) has resulted in increased demands on clinicians (Galea, Merchant, & Lurie, 2020). However, even before the pandemic, our understanding of
mental health workers’ own mental health was incomplete, and studies reported contradictoryﬁndings. Some research showed that mental health professionals generally coped well with theirwork and displayed better mental health than other workers (e.g., Koller & Hicks, 2016). Researchers
pointed to their greater coping and emotional regulation abilities and highlighted that their professional knowledge could have allowed them to deploy and maintain these strategies more eﬃciently than the general public (Manning-Jones et al., 2016; Norcross et al., 1986; Norcross 2005). Many

CONTACT Pascale Brillon
brillon.pascale@uqam.ca
Psychology Department, Université du Québec à Montréal, C.P.8888,
Succursale Centre-Ville, Montréal, Québec, Canada H3C 3P8
Supplemental data for this article can be accessed online at https://doi.org/10.1080/10615806.2023.2178646.
© 2023 Informa UK Limited, trading as Taylor & Francis Group604

P. BRILLON ET AL.

mental health professionals reported that providing mental health care was a source of growth,
fulﬁllment, and resilience for them (Kinman & Grant, 2020). However, several other studies
showed that being compassionate and empathic could come at a cost. When mental health professionals pay more attention to their clients’ well-being and neglect their own, providing mental
health care can become emotionally draining, which can lead to symptoms of psychological distressand reduced well-being (Figley, 2002). For instance, a meta-analysis of mental health professionals
found a pooled prevalence of 40% for emotional exhaustion (O’Connor et al., 2018). Anotherstudy investigated the prevalence of compassion fatigue amongst diﬀerent types of mental
health professionals (e.g., psychologists, social workers): between 7.7% and 28.6% of professionalgroups reported high levels of compassion fatigue (i.e., diminished ability to bear another’s
suﬀering; Figley, 2002; Rossi et al., 2012). In fact, mental health professions are amongst the mostat risk for compassion fatigue (Rivera-Kloeppel & Mendenhall, 2021) and can be subject to increased
risk of frustration, suicidal thoughts, helplessness, and professional turnover (e.g., Rössler, 2012;
Kleespies et al., 2011). These results suggest that while mental health professionals generally
display good coping and are resilient, they are not invulnerable and can also experience signiﬁcant
suﬀering. Thus, understanding what might curb the emergence of distress in this population should
be further researched.

Deﬁning self-care
The idea that one must take care of themselves to be able to better help others appears to be supported by research. Mental health professionals who report higher levels of distress tend to deliver
lower quality care, which may be damaging to clients receiving psychological services (e.g., Salyers
et al., 2017). Alarmingly, mental health professionals often struggle to prioritize their own needs intheir eagerness to help others (Skovholt et al., 2001). In this context, practicing suﬃcient self-care is
now considered one of the pillars of a healthy and ethical clinical practice by several mental healthprofessional associations. For example, the most recent Canadian Code of Ethics for Psychologists
states that it is necessary to “engage in self-care activities that help avoid conditions (e.g.,burnout) that could result in impaired judgment and interfere with their ability to beneﬁt and notharm others” (Canadian Psychological Association, 2017). Mental health professionals are encouraged to practice self-care to promote their well-being, and to bolster the quality of the careclients receive (Wise & Reuman, 2019).
In the simplest terms, self-care means taking care of oneself. However, from the perspective of
caregiving professionals, self-care generally designates activities, processes, and behaviors thatare self-initiated for the purpose of providing psychological relief (e.g., reducing stress anddepression), supporting resilience towards prevention (e.g., of compassion fatigue), and promoting
a subjective sense of well-being (Jiang et al., 2021; Lee & Miller, 2013; Posluns & Gall, 2020). The literature generally agrees that self-care is multidimensional, meaning that caring for oneself isachieved by implementing strategies in several areas of life (Jiang et al., 2021; Lee & Miller, 2013;
Posluns & Gall, 2020). For example, physical self-care aims to promote physical well-being (e.g., adequate sleep), psychological self-care is meant to promote self-awareness (e.g., journaling), emotional
self-care aims to maintain and promote positive emotions (e.g., spending time with loved ones),
spiritual self-care focuses on ﬁnding meaning in life (e.g., meditation), and, lastly, professional selfcare promotes healthy work conditions and the development of competence (e.g., getting adequate
supervision; Bloomquist et al., 2015). Therefore, self-care is a behavior that one can implement toadapt and maintain good psychological adjustment when faced with challenging times, naturally
decreasing or increasing the amount and type of self-care to suit their needs at any given time.
The COVID-19 pandemic has put signiﬁcant pressure on mental health professionals’ personal (Vindegaard & Benros, 2020) and professional lives (Galea et al., 2020). For this reason, investigating how
self-care practices and psychological adjustment naturally interact over time during a period of highstress is particularly pertinent as it allows us to capture how these professionals spontaneously

ANXIETY, STRESS, & COPING

605

adapt. Several lists of self-care strategies have been developed and shared with mental health professionals as ways to maximize their vitality. However, very few studies have measured the psychological impact of self-care on mental health or distress. Even fewer studies have tried to understandwhy some mental health professionals implement self-care.

Associations between self-care and psychological adjustment
In recent years, great eﬀort has been made to explore the associations between self-care practices
and indicators of psychological adjustment in samples of mental health professionals (see reviews by
Dattilio, 2015 and Posluns & Gall, 2020). Indeed, empirical research on self-care in mental health professionals indicates that a lack of self-care is associated with multiple unwanted outcomes, the moststudied being compassion fatigue, secondary traumatic stress, and burnout (Posluns & Gall, 2020). Ina sample of college students, less self-care was also associated with more symptoms of anxiety anddepression (Tam et al., 2021). In addition to the links found with reduced distress, several studies
have reported positive associations between self-care practices and good mental health, such aswith general well-being (Richards, et al., 2010). However, how other positive psychological adjustment indicators relate to the practice of self-care remains to be clariﬁed. For example, to our knowledge, no study has investigated how self-care relates to posttraumatic growth, that is, the signiﬁcant
positive changes that helping professionals can report in the aftermath of their highly challenging
work (Cann et al., 2010). Moreover, the directionality of the associations between self-care andpsychological adjustment remains empirically unexplored.

The directionality of associations between self-care and psychological adjustment
The associations found between self-care practices and psychological adjustment have been interpreted in the way that more self-care improves mental health. In fact, the most “obvious” causal
pathway suggests that self-care prevents unwanted outcomes and has psychological beneﬁts, implying directionality as ↑ self-care → ↑ mental health + ↓ distress (e.g., Posluns & Gall, 2020). However,
the available studies are largely cross-sectional and do not consider that self-care and mental healthcould have reciprocal relationships. Most importantly, they do not actually test the directionality ofthese links. Other studies have employed pre-post or controlled designs to test whether self-carebased programs, such as mindfulness training programs, are eﬃcient in improving the mental
health of trainees (see a meta-analysis by Colman et al., 2016) or seasoned clinicians (e.g., Eriksson
et al., 2018). These studies indicate that self-care-based interventions are beneﬁcial to mental
health professionals. However, they tend to focus on only one or two aspects of self-care (e.g., mindfulness, physical exercise; Colman et al., 2016) and do not really address whether naturalistic self-carepractices improve the psychological adjustment of mental health professionals.
Consideration of what predicts the use of self-care in mental health professionals has been muchless explored in studies. Knowing why mental health professionals tend to naturally increase theirself-care and why others do not (and are at risk of further deterioration) are critical issues to maintainthe health and longevity of mental healthcare workforce. We argue that there could be a directionaleﬀect where the psychological adjustment of mental health professionals could impact their tendency to implement self-care strategies (e.g., ↑ distress → ↑ self-care). For example, mental healthprofessionals who are struggling with anxiety may be more proactive in implementing self-carestrategies. Studies on physical exercise and anxiety suggest that exercise regulates negative psychological states such as anxiety and is reinforced as a regulation strategy over time (see review by
Asmundson et al., 2013). This activation could apply more broadly to self-care, as anxiety could
trigger an increase in self-care-orientated activities to downregulate anxiety. Alternatively, those
suﬀering from depression might be less inclined to implement self-care strategies despiteneeding them. Indeed, symptoms of depression are known to lead to reduced behavioral activationand engagement in pleasurable activities (American Psychiatric Association [APA], 2013), which

606

P. BRILLON ET AL.

could manifest themselves through reduced self-care. Spending time in nature, or seeking additional
clinical supervision, while helpful remedies to the pressures of their work, may seem insurmountable
and require too much energy when one’s mental health is already poor.
To our knowledge, very few studies have examined what predicts self-care practices. One interesting study found that a self-compassionate attitude in social workers was a unique and signiﬁcantpredictor of using both personal and professional self-care strategies (Jay Miller et al., 2019). Anotherstudy of interest investigated the reciprocal associations between perceived stress and self-care at
diﬀerent time points of undergraduate students’ semester (Simerly & Blackhart, 2021). Using across-lagged model, this study showed that self-care and stress had negative reciprocal associations
across time points (as stress increased, self-care behaviors decreased and vice versa). In sum, investigating the potentially reciprocal relationships between self-care and psychological adjustment is
critical to better understanding and promoting self-care, and harnessing its beneﬁts.

Objectives and hypothesis
Using a cross-lagged longitudinal design, this study aimed to better understand the directionality of
the associations between self-care practice and ﬁve indicators of psychological adjustment in mental
health professionals across two measurement time points spaced 10 months apart: well-being, posttraumatic growth, anxiety symptoms, depression symptoms, and compassion fatigue. Precisely, ourstudy tested whether the frequency of self-care at the ﬁrst time point predicted the psychologicaladjustment of mental health professionals at the second time point, and/or whether psychologicaladjustment at the ﬁrst time point was associated with an increased or reduced self-care practice atthe second time point, both time points occurring during the COVID-19 pandemic. Studies havefound that self-care was associated with better mental health (i.e., less distress and more wellbeing). Therefore, we expected that self-care at T1 would be positively associated with well-being
and posttraumatic growth and negatively associated with anxiety symptoms, depression symptoms,
and compassion fatigue at T2. Given the lack of research on predictors of self-care practice, nofurther hypothesis was posited.

MethodParticipants and procedure
A total of 732 mental health professionals participated in the ﬁrst wave of the study (T1 from May 1
to July 20, 2020) and, of these, 358 also completed the second wave (March 11 to June 6, 2021) andwere included in the current study. Inclusion criteria were to be 20 years of age or older, to be currently working in Canada as a mental health professional, to be suﬃciently proﬁcient in English or
French (both oﬃcial Canadian languages), and to not have any work interruptions because of the
COVID-19 pandemic. The ﬁnal sample (i.e., those who participated in T1 and T2) was 42.31 yearsof age on average (SD = 11.11), and mostly identiﬁed as women (89.4%). In terms of relationshipstatus, 14.0% reported being single, 14.8% in dating relationships, 62.0% married or in a civil
union, and 9.2% divorced, separated or widowed. As expected, the sample was mostly highly educated: 8.9% had a technical degree, 30.7% a bachelor’s or ﬁrst cycle university degree, 42.5% amaster’s degree, and 16.4% completed doctoral or postdoctoral studies. The types of mental
health professionals included in the study were quite diverse. The sample consisted of psychologists(34.6%), psychosocial counselors (18.2%), social workers (12.0%), psychoeducators (10.3%), criminologists (3.4%), sexologists (2.8%), and psychiatrists (0.8%). Of note, 17.9% of the sample reported
being another type of mental health worker, citing professions such as art therapists, mental
health nurses, counselors, and neuropsychologists. The sample mostly worked in the public sector(41.1%; e.g., hospitals, youth protection) or community organizations (29.3%). However, 22.9%
worked in private practice. Lastly, 94.4% of the sample were currently doing clinical work as

ANXIETY, STRESS, & COPING

607

mental health workers during the pandemic crisis: 15.9% worked exclusively in person, 59.2% exclusively in telehealth, and 23.5% in a combination of the two modalities. To assess sample bias, the T2
responders were compared to the T2 non-responders using Chi squares and t-tests on backgroundvariables (e.g., age, gender), self-care behaviors, and psychological adjustment indicators at T1. A
Bonferroni correction to account for the risk of bias associated with multiple comparisons determined that the critical p-value for the t-test was 0.007. Results showed that T2 responders were signiﬁcantly older (M = 42.31, SD = 11.13) than the T2 non-responders (M = 39.72, SD = 11.11; t(730) =−3.14, p = .002, Cohen’s d = .23), but no other signiﬁcant diﬀerences were found.
Participants were recruited through various professional associations of mental health professionals who shared our participation invitation to their members via email. Participants were
informed that the study was conﬁdential. These invitations also contained a link to a web platform
where they completed the written consent form and the survey (approximately 30 min). As compensation for their time, participants were entered into a draw for one of three prizes of $125. Ethics
approval for the current study was obtained from the University of Quebec in Montreal Institutional
Ethics Committee on Human Research where the study was conducted.

Measures
Cronbach’s alpha values for all instruments can be found in Table 1.

Demographics indicators
For all participants, demographic data and characteristics of their work and current clinical practicewere collected.

Self-care practice
The frequency of engagement in 45 self-care behaviors over the past 30 days was measured using
the Self-Care Practice Scale (SCPS; Bloomquist et al., 2015). This measure assesses ﬁve domains of selfcare practice – physical, professional, emotional, psychological, and spiritual, with each domain
including eight to twelve self-care behaviors. Participants rated the frequency with which they
engaged in each using a 6-point Likert scale (0 = never to 6 = very frequently). The total score wasused (possible range: 0 to 270). The SCPS was developed and validated in a sample of social
workers and demonstrated strong internal consistency (α = .90; Bloomquist et al., 2015) as was
also found in our study (see Table 1).
Table 1. Average practice of self-care and levels of psychological indicators across time points.
T1
Overall Self-Care PracticePhysicalProfessional
Emotional
Psychological
SpiritualWell-Being
Posttraumatic Growth
Anxiety Symptoms
Depression Symptoms
Compassion Fatigue

T2

α

M

SD

α

M

SD

t(357)p

Cohen’s d

.90
–
–
–
–
–
.68
.88
.89
.86
.86

150.09
3.73
3.36
3.66
3.30
2.57
51.97
22.20
11.89
14.60
45.54

25.32
0.74
0.68
0.75
0.80
0.82
5.56
7.61
4.23
4.79
9.07

.88
–
–
–
–
–
.69
.88
.90
.87
.87

150.69
3.89
3.37
3.57
3.30
2.54
52.30
22.02
12.56
14.99
46.99

24.48
0.68
0.65
0.77
0.81
0.82
5.62
7.71
4.62
4.82
9.56

−0.58
−4.72
−0.40
2.76
0.14
0.89
−1.26
0.52
−3.04
−1.67
−3.42

.563
<.001
.688
.006
.887
.375
.104
.606
.003
.097
<.001

−0.031−0.250−0.021
0.146
0.008
0.047
−0.0670.027−0.161−0.088−0.181

Note. Participants indicated the frequency to which they practiced each self-care behavior using the following scale: 1 (Never), 2(Rarely – Once a Month), 3 (Sometimes – A few times a month), 4 (Often – Weekly), 5 (Very Often – A Few Times a Week), and 6(Frequently – Almost Daily to Daily). Their mean rating for the self-care items is presented. All other scores represent the mean
total score. Cohen’s d benchmarks (1988) are small (d = 0.20), medium (d = 0.50), and large (d = 0.80) eﬀect sizes.

608

P. BRILLON ET AL.

Psychological adjustment indicators
Eudaimonic well-being. The short version of the Psychological Well-Being Scale (PWB; Ryﬀ & Keyes,
1995) was used to measure eudemonic well-being. Only three of the six subscales were used: (1) selfacceptance, (2) purpose in life, and (3) personal growth, so as not to confound eudemonic well-being
with psychological needs (e.g., Philippe et al., 2012). Participants rated their agreement with each of
the nine items (e.g., “I think it is important to have new experiences that challenge how I think about
myself and the world.”) on the basis of how they felt about themselves and their lives on a scaleranging from 0 to 7 (0 = strongly disagree to 7 = strongly agree). The total score could range from0 to 63. The PWB Scale has adequate psychometric properties with distinct factors for all six subscales(Ryﬀ & Keyes, 1995). Further, this adapted version of the PWB Scale has demonstrated good internalconsistency in a previous study (Philippe et al., 2012).

Posttraumatic growth. The Posttraumatic Growth Inventory – Short Form (PTGI-SF; Cann et al.,2010) measures the degree to which participants experience positive changes in their lives in
the aftermath of adversity. Participants rated 10 items deﬁning changes (e.g., “I established a
new path for my life.”) on a scale ranging from 0 to 5 (0 = I did not experience this change to 5
= I experienced this change to a very great degree). The total ranged from 0 to 50. The PTGI-SF
has been validated in several samples (Cadell et al., 2015; Cann et al., 2010) and possesses adequate psychometric properties.

Anxiety symptoms. The Generalized Anxiety Disorder 7 (GAD- 7; Spitzer et al., 2006) assesses the presence and severity of anxiety symptoms in the past two weeks. Participants rated seven items (e.g.,“Not being able to stop or control worrying”) on a Likert scale ranging from 0 to 3 (0 = not at all
to 3 = nearly every day). The total score could range from 0 to 21, with a cut-oﬀ score of ≥10 for moderate or severe anxiety. The GAD-7 has been validated in several samples, it has demonstrated goodsensitivity for generalized anxiety, panic, social anxiety and posttraumatic stress disorder, and possesses good psychometric properties (Kroenke et al., 2010).
Depressive symptoms. The Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) assesses
symptoms of depression (as described in DSM-IV) over the past two weeks. Participants rated
nine items (e.g., feeling down, depressed, or hopeless) on a Likert scale ranging from 0 = never to
3 = almost every day. The total score could range from 0 to 27, with a cut-oﬀ score of ≥10 for moderate or severe depression symptoms. A systematic review of depression measures recently identiﬁed the PHQ-9 as the most reliable screening tool for depression symptoms as it demonstrated
excellent psychometric properties (El-Den et al., 2018).

Compassion fatigue. Compassion fatigue was measured using the ﬁfth version of the Professional
Quality of Life Scale (ProQOL-5; Stamm, 2015). This instrument includes three subscales composed of
10 items each: burnout, secondary traumatic stress, and compassion satisfaction experienced in thelast 30 days. Together, burnout and secondary traumatic stress indicate the degree of compassion
fatigue. Therefore, for this study, only these two compassion fatigue subscales were used. Participants rated the 20 items (e.g., “I ﬁnd it diﬃcult to separate my personal life from my life as a[helper].”) on a Likert scale ranging from 1 = never to 5 = very often. The total score was used (possible range: 30 to 150). The ProQOL-5 has been well validated and has demonstrated strong psychometric properties (Geoﬀrion et al., 2019; Stamm, 2015).
Data analysis
For preliminary analyses, SPSS 26.0 was used, and Mplus 7.0 was used for the cross-lagged
model. There was no missing data. First, paired t-tests were performed to compare the self-

ANXIETY, STRESS, & COPING

609

care practices and psychological adjustment of the sample at both time points. Next, Pearson
correlations were conducted to test the associations between the variables of interest. Then,a two-wave cross-lagged model was constructed (see Figure 1). Two types of eﬀects were
tested: (1) autoregressive eﬀects that examined the stability of the same variable over time;and (2) cross-lagged eﬀects that tested the directionality of two variables over time. Thesecross-lagged eﬀects allowed us to establish whether (a) self-care practice preceded psychological adjustment indicators; (b) adjustment indicators preceded self-care practice, or (c) both concepts inﬂuenced each other over the two-time points. Because an age diﬀerence was foundbetween T2 non-responders and responders, age was entered as a control variable in the
cross-lagged model.
Since a fully cross-lagged model requires the estimation of all possible path combinations, thisproduces a saturated model containing 0 degrees of freedom, making it impossible to obtain ﬁt
indices. Therefore, to obtain an optimal model and ﬁt indices, it is recommended to undertake
post hoc modiﬁcations to the model where nonsigniﬁcant paths are progressively removed until
all paths are statistically signiﬁcant, and the model is the most parsimonious (Ullman & Bentler,2012). Finally, where reciprocal associations were found between self-care practices and a psychological adjustment indicator, a post-hoc cross lagged model was constructed to investigate how
types of self-care (i.e., physical, professional, emotional, psychological, and spiritual) interactedwith the indicator over time. The ﬁt of the cross-lagged models was evaluated by several indicesaccording to recommended guidelines (Hu & Bentler, 1999): the chi-square statistics, the root
mean square error of approximation (RMSEA) < .10 (superior ﬁt ≤ .06), the standardized root meansquared residual (SRMR) < .10, the comparative ﬁt index (CFI) and the Tucker-Lewis Index (TLI) >0.90 (superior ﬁt ≥ 0.95).

Figure 1. Two-wave cross-lagged model of self-care practice and psychological adjustment indicators.
Note. Coeﬃcients are standardized. Covariation paths between variables at each time point have been omitted from the ﬁgure for clarity. However,they are presented in Supplementary material 2. *p < .05. **p < .01. ***p < .001.

610

P. BRILLON ET AL.

Results
Self-care practice
At both time points, the frequency and type of self-care practices reported by mental health professionals were similar. They reported using some self-care behaviors quite frequently while practicing others only rarely. Therefore, when considering the average frequency of all forms of self-care,mental health professionals reported that they did not routinely engage in self-care practice (MT1 =3.34, SD T1 = 0.56; MT2 = 3.35, SD T2 = 0.54 where 3 indicates Sometimes – A few times a month). As
seen in Table 1, at both measurement times, physical self-care was most frequent, followed in orderby emotional, professional, and psychological self-care. Spiritual self-care activities were notably lesspracticed than all other domains. Speciﬁcally, several activities were rated on average at a 4 or above(Often–Frequently). They included practicing healthy eating, sleeping regularly, engaging in hobbies
and exercise (physical), laughing, spending time with those one enjoys (emotional), taking time tochat with colleagues, setting limits with clients, and discussing cases with colleagues (professional),
taking time for reﬂection, setting personal goals (psychological), and spending time in nature (spiritual). A few self-care activities were rarely practiced as a whole, with an average rating of 2 or lower(Rarely–Never). These included participating in a peer support group, negotiating professional needs(e.g., beneﬁts), participating in stress management training (professional), writing in a journal(psychological), praying, spending time in a spiritual community, and practicing yoga (spiritual).
When comparing the self-care practice between the two time points, the frequency of each typeof self-care was similar with the exception of physical self-care which signiﬁcantly increased at T2.
However, the eﬀect size was small (Cohen’s d = 0.25). A detailed description of mental healthworkers’ self-care practice can be found in the Supplementary material.

Preliminary analysis
Paired T-tests examined whether changes were reported in the indicators of psychological adjustment across study waves (see Table 1). There were no statistically signiﬁcant diﬀerences in themean levels of well-being, posttraumatic growth, and depression reported by the sample. A slightincrease in anxiety and compassion fatigue was found. However, eﬀect sizes (ds of respectively−0.16 and −0.18) indicated these trends were minor. The mean, standard deviation, and intercorrelations of the study variables are shown in Table 2. At both time points, self-care was signiﬁcantly
associated with better mental health (i.e., more well-being and post-traumatic growth, and fewer
anxiety symptoms, depression symptoms, and compassion fatigue).

Cross-lagged model of self-care and psychological adjustment indicators
To investigate the directionality of associations between self-care and psychological adjustment
indicators, a two-wave cross-lagged model was constructed using six variables: self-care, wellbeing, posttraumatic growth, anxiety symptoms, depression symptoms, and compassion fatigue.
After progressively removing non-statistically signiﬁcant paths, the ﬁnal parsimonious model had
an adequate ﬁt, χ 2 (358) = 48.30, p = .014; CFI = 0.98; TLI = 0.97; RMSEA = .04 [90% CI: .02, .06];
SRMR = .04. The model is illustrated in Figure 1 and standardized coeﬃcients for all paths are presented in Supplementary material 2. Results indicated that all autoregressive paths were statistically signiﬁcant (βs between .43 and .70) suggesting that the variables were relatively stable
over time. Several cross-lagged eﬀects were also found. Self-care practices at T1 predicted
increased well-being and posttraumatic growth at T2, as well as lower anxiety and depression
symptoms at T2. Only anxiety at T1 predicted more self-care practices at T2. In terms of control
variables, age was associated with more self-care, less well-being, less anxiety and depression
symptoms at T2.

Table 2. Descriptive statistics and correlation matrix of T1 and T2 variables entered into the cross-lagged model.
Variable
1. SCT1
2. WBT1
3. PTGT1
4. AnxT1
5. DepT1
6. CF T1
7. SC T2
8. WBT2
9. PTGT2
10. AnxT2
11. DepT2
12. CFT2
Age1

2.30***.32***−.28***−.36***−.17**.69***.27***.29***−.23***−.27***
−.10
.15**

–
.07
−.31***−.38***−.29***.21***.63***.02−.15**−.27***−.19***
−.06

–

3

–
.05
−.01
.03
.27***.04.58***
.07
.03
.11*
.08

4

5

6

7

.78***.60**−.11*−.21**
.11*
.57**
.48**
.43**
−.17**–.54***−.18***−.26***.07.51***.59***.41***−.18***–−.04−.23***.14***.41***.40***.62***.002–.30***.37***−.23***−.32***−.07.22***

–

8

9

10

.07
−.19***−.36***−0.23***
−.10*

–
.11*
−.04
.16**
.04

–
.71***.53***−.23***––.51***−.03
ANXIETY, STRESS, & COPING

Note. SC = Self-Care; WB = Well-Being; PTG = Posttraumatic Growth; Anx = Anxiety; Dep = Depression; CF = Compassion Fatigue. *p < .05. **p < .01. ***p < .001.

11

611

612

P. BRILLON ET AL.

Post hoc cross-lagged model of types of self-care and anxiety symptoms
Because reciprocal associations were found between self-care and anxiety symptoms, an additionalcross-lagged model was constructed using the ﬁve types of self-care, physical, professional, emotional,
psychological, and spiritual, and anxiety symptoms (see Figure 2). After progressively removing nonstatistically signiﬁcant paths, the ﬁnal parsimonious model had a good ﬁt, χ 2 (358) = 19.35, p = .563; CFI= 1.00; TLI = 1.00; RMSEA < .001 [90% CI: .00, .04]; SRMR = .03. All autoregressive paths (βs between .47
and .69) indicated that all types of self-care practice were relatively stable over time. Cross-lagged
eﬀects indicated that emotional self-care at T1 predicted decreased anxiety symptoms at T2 (β= –.14). In turn, anxiety symptoms at T1 predicted more professional self-care at T2 (β = .09).

Discussion
Using a cross-lagged model, the present study was the ﬁrst to explore the longitudinal reciprocal
relationships between self-care practices, well-being, posttraumatic growth, anxiety symptoms,

Figure 2. Post hoc two-wave cross-lagged model of type of self-care practice and anxiety symptoms.
Note. Coeﬃcients are standardized. Covariation paths between variables at each time point have been omitted for clarity. *p < .05. **p < .01. ***p
< .001.

ANXIETY, STRESS, & COPING

613

depression symptoms, and compassion fatigue in a sample of mental health professionals. The main
pattern of associations found suggested that practicing self-care predicted better psychologicaladjustment at the second time point: professionals who practiced these strategies at T1 showed adecrease in anxiety and depression, and an increase in well-being and post-traumatic growth afterwards. This ﬁnding is very important as it supports the many theoretical conceptualizations of the
expected outcomes of self-care strategies (e.g., Barnett, et al., 2009; Bloomquist et al, 2015;
Posluns & Gall, 2020; Saakvitne & Pearlman, 1996). These theoretical models also suggest that
self-care strategies impact both positive and negative psychological adjustment indicators. Our
results provide new longitudinal support for this idea by ﬁnding that naturalistic self-care leads toboth a decrease in distress and an improvement in positive aspects of mental health. Including a
subjective burden or quality of life measure could better capture the overall combined eﬀects ofself-care in distress reduction and mental health improvement.
A key feature of this study is that it allowed us to investigate whether psychological adjustment
indicators could also inﬂuence how much self-care mental health professionals implemented. A reciprocal relationship was found between self-care and anxiety symptoms: anxiety symptoms predicted
an increased use of self-care at the second time point, in turn, self-care predicted a subsequent
decrease in anxiety symptoms. In fact, anxiety was found to predict an increase in the amount ofself-care practiced. More speciﬁcally, the post-hoc cross-lagged model indicated that anxiety predicted an increase in professional self-care at the later timepoint This could be due to the negative
activation and agitation that can accompany anxious reactions which may lead individuals to invest
in self-care strategies to reduce these unpleasant sensations (Asmundson et al., 2013; Eysenck &Calvo, 1992). The ﬁnding that anxiety seems to naturally generate a boost in professional self-care
could indicate that the source of this anxiety is work-related or related to work-life balance issues
for instance. However, this should be investigated further. The post-hoc cross-lagged model also
found that emotional self-care was most predictive of reduced anxiety over time. In contrast,
there was no signiﬁcant cross-lagged association between depression symptoms at T1 and subsequent self-care: symptoms of depression did not predict increased self-care; however, they did
not predict a decrease in self-care either. Depressive symptoms often lead to apathy, despondency
and demotivation (APA, 2013), which could explain why self-care strategies do not increase between
the two time points. However, while mental health professionals do not tend to adapt their self-carestrategies when struggling with depressive symptoms, self-care did appear to be a useful remedy for
depression (as a signiﬁcant association was found between self-care at T1 and depression at T2).
Possible avenues to explore could be to promote the variety of self-care strategies, and to encouragemental health workers to explore diﬀerent self-care strategies that may be less demanding and feasible even when depressive symptoms are present. Future studies should also consider other variables that could predict how much self-care mental health professionals practice. Speciﬁcally,
investigating how work-related factors (e.g., workplace culture, accessibility to childcare, balanceof work-life needs), or other psychological variables (e.g., assertiveness, emotional awareness, avoidant coping style, self-eﬃcacy evaluation, guilt sensitivity) might predict the use of self-care appear
to be fruitful avenues in this ﬁeld of research.
Interestingly, we found that self-care did not signiﬁcantly predict subsequent changes in compassion fatigue. Therefore, our results did not support the current conceptualization of self-care
as an eﬀective way of preventing the speciﬁc eﬀects of helping people who are suﬀering (Figley,2002). Previous research on this topic is limited as a review only identiﬁed nine studies on the mitigating eﬀect of self-care on compassion fatigue, all of which were cross-sectional (Rivera-Kloeppel &Mendenhall, 2021): ﬁve of these studies did not ﬁnd that self-care was strongly related to compassion fatigue. Although the mechanisms for this ﬁnding remain to be investigated, one explanation could be that self-care does not prevent professionals from experiencing compassion
fatigue but could rather prevent compassion fatigue from turning into distress in everyday life. In
fact, signiﬁcant cross-lagged associations were found between compassion fatigue at T1 andanxiety and depression at T2. This supports compassion fatigue as a risk factor for mental health

614

P. BRILLON ET AL.

professionals (Rivera-Kloeppel & Mendenhall, 2021). It also suggests that self-care strategies might
not be the right and only way to prevent a syndrome as important as compassion fatigue andthat more focused strategies speciﬁcally targeting relational aspects of mental health professionals’
clinical practice might be relevant (e.g., Can & Watson, 2019). This could be examined in a three-time
point cross-lagged model using self-care as a mediator of the association between compassion
fatigue and psychological adjustment indicators.
Our results also showed another interesting cross-lagged association: a signiﬁcant positive
relation between compassion fatigue at T1 and posttraumatic growth at T2 (β = .15). Posttraumatic
growth designates the positive changes that one can experience as a result of a painful experience:
having a greater appreciation of life, a deeper self-understanding, a greater spirituality, and an
improvement in the quality of social relationships (Cann et al., 2010). Therefore, our results
suggest that compassion fatigue is associated with an increase in distress and posttraumatic
growth over time. This aligns with Joseph, Murphy, and Regel’s model of post-traumatic growth(2012) which suggests that when individuals experience psychological pain, they engage in extensive reﬂection about their core beliefs, attempt to narrow the cognitive gap between their expectations and reality, and seek to make sense of their experience. This cognitive work can maintaincompassion fatigue but can also bolster posttraumatic growth.
Other ﬁndings are worth mentioning. First, we found that mental health professionals reported
only engaging in a moderate amount of self-care at both time points. This data reaﬃrms theﬁndings of other studies (e.g., Jay Miller et al., 2019) and suggests that more eﬀorts may beneeded for mental health professionals to truly adopt self-care as part of their clinical practice.
Second, as both time points took place during active phases of the COVID-19 pandemic, thestable levels of each of the psychological indicators suggest that mental health professionals
appeared relatively stable despite the ongoing COVID-19-related public health crisis. However,given that mental health professionals were not assessed prior to this pandemic, we do not know
how their psychological adjustment might compare to pre-pandemic times. Third, we found thatyounger professionals practiced less self-care and suﬀered more anxiety and depression symptoms.
This aligns with other studies that have shown that younger and less experienced clinicians are lessresilient and face a greater risk of professional distress (Jennings & Skovholt, 2016); these conditions
have been aggravated during the pandemic crisis (Probst et al., 2020).
In sum, this study advances current knowledge of both the psychological impact of self-care andof why mental health professionals change their self-care practices. The ﬁnal cross-lagged model
conﬁrmed that self-care predicts subsequent changes in psychological adjustment. It also provides
initial evidence of the reciprocal relationships between self-care practices and psychological adjustment, speciﬁcally of anxiety, over time. In fact, only one reciprocal relationship was found where
anxiety symptoms and self-care practices both impacted each other over time. Knowing that
there appears to be a downregulation cycle of associations between anxiety and self-care is important; when mental health professionals faced anxiety, they appeared to naturally increase their selfcare, thereby experiencing a decrease in this anxiety. This might mean that more attention should be
paid to helping mental health professionals combat compassion fatigue and overcome symptoms ofdepression, as these two forms of distress appear to not generate the boost in self-care that these
professionals may need. Because mental health professionals are needed now more than ever(Galea et al., 2020) and because the mental health of these practitioners is a key determinant of
their ability to provide high quality care (Laverdière et al., 2018; Salyers et al., 2017), oﬀering early
but also regular support in their career is essential for them to adopt healthy and vitalizing selfcare strategies and prevent the onset of distress.

Strengths, limitations, and future research
Mental health professionals are expected to face several important challenges in the coming years(e.g., shortages of qualiﬁed staﬀ, increased demands and more diﬃcult clientele related to the

ANXIETY, STRESS, & COPING

615

pandemic; Peachy et al., 2013; Rimmer, 2021). Finding ways of promoting mental health workers’
well-being will be paramount: self-care could be one of the key ways of preserving their mental
health. In addition to the important takeaways of this study, it ﬁlls an important gap in research.
To our knowledge, this study is the ﬁrst to examine (1) the longitudinal impact of naturalistic selfcare on (2) both positive and negative psychological indicators of mental health, and to consider(3) whether psychological adjustment predicts the use of self-care. In fact, this study used a large
sample composed of several types of mental health professionals which allowed to test acomplex model. Despite these strengths, the results of the study should be interpreted with some
limitations in mind. First, although a causal relationship was implied in this study, additional
studies are needed to further explore the complex dynamic relationship between self-care andpsychological adjustment. Speciﬁcally, considering whether mediators or moderators that could
explain some of the associations found (or lack thereof) would be important. Second, as only twotime points were included, some of the more complex associations could not be investigated; forinstance, it would not be surprising to learn that self-care practices and anxiety operate in a cyclic
pattern when assessed on multiple occasions. Third, a signiﬁcant proportion of participants did
not complete the second assessment. However, the participants that dropped out did not appear
much diﬀerent from those who completed both assessments, which suggests results remained
representative. Fourth, while all types of mental health professionals were included in our sample,
they were not equally represented, with some groups being overrepresented and others being
underrepresented. Thus, caution should be exercised when generalizing our results to all types ofmental health professionals. Lastly, the assessments of self-care and psychological adjustment
were done using self-report measures for which bias is inevitable. Future studies could use moreobjective indicators of psychological adjustment, such as clinician or peer-rated assessments.
Despite these limitations, this study sheds new light on the interrelations between self-care practices
and psychological adjustment of an at-risk population during a particularly stressful period.

Acknowledgments
We sincerely thank the mental health professionals who took part in this study for their willingness to share their experience and the professional associations who kindly assisted us.

Disclosure statement
No potential conﬂict of interest was reported by the authors.

Funding
The author(s) reported there is no funding associated with the work featured in this article.

ORCID
Pascale Brillon
http://orcid.org/0000-0002-0175-095X
Michelle Dewar
http://orcid.org/0000-0001-8492-1365
Alison Paradis
http://orcid.org/0000-0001-9001-0058
Frederick Philippe
http://orcid.org/0000-0001-6997-8072

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/
10.1176/appi.books.9780890425596
Asmundson, G. J., Fetzner, M. G., DeBoer, L. B., Powers, M. B., Otto, M. W., & Smits, J. A. (2013). Let’s get physical: A contemporary review of the anxiolytic eﬀects of exercise for anxiety and its disorders. Depression and Anxiety, 30(4), 362–
373. https://doi.org/10.1002/da.22043

616

P. BRILLON ET AL.

Barnett, J. E., & Cooper, N. (2009). Creating a culture of self-care. Clinical Psychology: Science and Practice, 16(1), 16–20.
https://doi.org/10.1111/j.1468-2850.2009.01138.x
Bloomquist, K. R., Wood, L., Friedmeyer-Trainor, K., & Kim, H. W. (2015). Self-care and professional quality of life:
Predictive factors among MSW practitioners. Advances in Social Work, 16(2), 292–311. https://doi.org/10.18060/18760
Cadell, S., Suarez, E., & Hemsworth, D. (2015). Reliability and validity of a French version of the posttraumatic growthinventory. Open Journal of Medical Psychology, 04(02), 53–65. https://doi.org/10.4236/ojmp.2015.42006
Can, N., & Watson, J. C. (2019). Individual and relational predictors of compassion fatigue among counselors-in-training.
The Professional Counselor, 9(4), 285–297. https://doi.org/10.15241/nc.9.4.285
Canadian Psychological Association. (2017). Canadian code of ethics for psychologists (4th ed.). ISBN 978-1-926793-11-5.
Cann, A., Calhoun, L. G., Tedeschi, R. G., Taku, K., Vishnevsky, T., Triplett, K. N., & Danhauer, S. C. (2010). A short form of theposttraumatic growth inventory. Anxiety, Stress & Coping, 23(2), 127–137. https://doi.org/10.1080/
10615800903094273
Colman, D. E., Echon, R., Lemay, M. S., McDonald, J., Smith, K. R., Spencer, J., & Swift, J. K. (2016). The eﬃcacy of self-carefor graduate students in professional psychology: A meta-analysis. Training and Education in Professional Psychology,
10(4), 188–197. https://doi.org/10.1037/tep0000130
Dattilio, F. M. (2015). The self-care of psychologists and mental health professionals: A review and practitioner guide.
Australian Psychologist, 50(6), 393–399. https://doi.org/10.1111/ap.12157
El-Den, S., Chen, T. F., Gan, Y. L., Wong, E., & O’Reilly, C. L. (2018). The psychometric properties of depression screening
tools in primary healthcare settings: A systematic review. Journal of Aﬀective Disorders, 225, 503–522. https://doi.org/
10.1016/j.jad.2017.08.060
Eriksson, T., Germundsjö, L., Åström, E., & Rönnlund, M. (2018). Mindful self-compassion training reduces stress andburnout symptoms among practicing psychologists: A randomized controlled trial of a brief web-based intervention.
Frontiers in Psychology, 9, 2340. https://doi.org/10.3389/fpsyg.2018.02340
Eysenck, M. W., & Calvo, M. G. (1992). Anxiety and performance: The processing eﬃciency theory. Cognition & Emotion, 6(6), 409–434. https://doi.org/10.1080/02699939208409696
Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of Clinical Psychology, 58(11),1433–1441. https://doi.org/10.1002/jclp.10090
Galea, S., Merchant, R. M., & Lurie, N. (2020). The mental health consequences of COVID-19 and physical distancing: theneed for prevention and early intervention. JAMA Internal Medicine, 180(6), 817–818. https://doi.org/10.1001/
jamainternmed.2020.1562
Geoﬀrion, S., Lamothe, J., Morizot, J., & Giguère, CÉ. (2019). Construct validity of the Professional Quality of Life (ProQoL)
scale in a sample of child protection workers. Journal of Traumatic Stress, 32(4), 566–576. https://doi.org/10.1002/jts.
22410
Hu, L. T., & Bentler, P. M. (1999). Cutoﬀ criteria for ﬁt indexes in covariance structure analysis: Conventional criteria versus
new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/
10705519909540118
Jay Miller, J., Lee, J., Niu, C., Grise-Owens, E., & Bode, M. (2019). Self-compassion as a predictor of self-care: A study ofsocial work clinicians. Clinical Social Work Journal, 47(4), 321–331. https://doi.org/10.1007/s10615-019-00710-6
Jennings, L., & Skovholt, T. M. (2016). Expertise in counseling and psychotherapy: Master therapist studies from around theworld. Oxford University Press.
Jiang, X., Topps, A. K., & Suzuki, R. (2021). A systematic review of self-care measures for professionals and trainees.
Training and Education in Professional Psychology, 15(2), 126–139. https://doi.org/10.1037/tep0000318
Joseph, S., Murphy, D., & Regel, S. (2012). An aﬀective-cognitive processing model of post-traumatic growth. ClinicalPsychology & Psychotherapy, 19(4), 316–325. https://doi.org/10.1002/cpp.1798
Kinman, G., & Grant, L. (2020). Emotional demands, compassion and mental health in social workers. Occupational
Medicine, 70(2), 89–94. https://doi.org/10.1093/occmed/kqz144
Kleespies, P. M., Van Orden, K. A., Bongar, B., Bridgeman, D., Bufka, L. F., Galper, D. I., Hillbrand, M., & Yuﬁt, R. I. (2011).
Psychologist suicide: Incidence, impact, and suggestions for prevention, intervention, and postvention. Professional
Psychology: Research and Practice, 42(3), 244–251. https://doi.org/10.1037/a0022805
Koller, S. L., & Hicks, R. E. (2016). Psychological capital qualities and psychological well-being in Australian mental healthprofessionals. International Journal of Psychological Studies, 8(2), 41–53. https://doi.org/10.5539/ijps.v8n2p41
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of
General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2010). The patient health questionnaire somatic, anxiety, anddepressive symptom scales: A systematic review. General Hospital Psychiatry, 32(4), 345–359. https://doi.org/10.
1016/j.genhosppsych.2010.03.006
Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. (2018). Psychological health proﬁles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health. Canadian Psychology / Psychologie Canadienne, 59(4), 315–
322. https://doi.org/10.1037/cap0000159
Lee, J. J., & Miller, S. E. (2013). A self-care framework for social workers: Building a strong foundation for practice. Families
in Society: The Journal of Contemporary Social Services, 94(2), 96–103. https://doi.org/10.1606/1044-3894.4289

ANXIETY, STRESS, & COPING

617

Manning-Jones, S., de Terte, I., & Stephens, C. (2016). Secondary traumatic stress, vicarious posttraumatic growth, andcoping among health professionals: A comparison study. New Zealand Journal of Psychology (Online), 45(1), 20–29.
Norcross, J. C. (2005). The psychotherapist’s own psychotherapy: Educating and developing psychologists. American
Psychologist, 60(8), 840–850. https://doi.org/10.1037/0003-066X.60.8.840
Norcross, J. C., Prochaska, J. O., & Diclemente, C. C. (1986). Self-change of psychological distress: Laypersons’ vs. psychologists’ coping strategies. Journal of Clinical Psychology, 42(5), 834–840. https://doi.org/10.1002/1097-4679(198609)42:5<834::AID-JCLP2270420527>3.0.CO;2-A
O’Connor, K., Neﬀ, D. M., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and metaanalysis of prevalence and determinants. European Psychiatry, 53, 74–99. https://doi.org/10.1016/j.eurpsy.2018.06.
003
Peachey, D., Hicks, V., & Adams, O. (2013). An imperative for change: Access to psychological services for Canada. HealthIntelligence Inc.
Philippe, F. L., Koestner, R., Beaulieu-Pelletier, G., Lecours, S., & Lekes, N. (2012). The role of episodic memories in current
and future well-being. Personality and Social Psychology Bulletin, 38(4), 505–519. https://doi.org/10.1177/
0146167211429805
Posluns, K., & Gall, T. L. (2020). Dear mental health practitioners, take care of yourselves: A literature review on self-care.
International Journal for the Advancement of Counselling, 42(1), 1–20. https://doi.org/10.1007/s10447-019-09382-w
Probst, T., Humer, E., Stippl, P., & Pieh, C. (2020). Being a psychotherapist in times of the novel coronavirus disease.
Frontiers in Psychology, 11, 559100. https://doi.org/10.3389/fpsyg.2020.559100
Richards, K., Campenni, C., & Muse-Burke, J. (2010). Self-care and well-being in mental health professionals: The mediating eﬀects of self-awareness and mindfulness. Journal of Mental Health Counseling, 32(3), 247–264. https://doi.org/10.
17744/mehc.32.3.0n31v88304423806
Rimmer, A. (2021). Mental health: Staﬀ shortages are causing distressingly long waits for treatment, college warns. BMJ,
2021(375), n2439. https://doi.org/10.1136/bmj.n2439
Rivera-Kloeppel, B., & Mendenhall, T. (2021). Examining the relationship between self-care and compassion fatigue inmental health professionals: A critical review. Traumatology. https://doi.org/10.1037/trm0000362
Rossi, A., Cetrano, G., Pertile, R., Rabbi, L., Donisi, V., Grigoletti, L., Curtolo, C., Tansella, M., Thornicroft, G., & Amaddeo, F.
(2012). Burnout, compassion fatigue, and compassion satisfaction among staﬀ in community-based mental healthservices. Psychiatry Research, 200(2-3), 933–938. https://doi.org/10.1016/j.psychres.2012.07.029
Rössler, W. (2012). Stress, burnout, and job dissatisfaction in mental health workers. European Archives of Psychiatry andClinical Neuroscience, 262(2), 65–69. https://doi.org/10.1007/s00406-012-0353-4
Ryﬀ, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social
Psychology, 69(4), 719–727. https://doi.org/10.1037/0022-3514.69.4.719
Saakvitne, K. W., & Pearlman, L. A. (1996). Transforming the pain: A workbook on vicarious traumatization. WW Norton &Co.
Salyers, M. P., Bonﬁls, K. A., Luther, L., Firmin, R. L., White, D. A., Adams, E. L., & Rollins, A. L. (2017). The relationshipbetween professional burnout and quality and safety in healthcare: A meta-analysis. Journal of General Internal
Medicine, 32(4), 475–482. https://doi.org/10.1007/s11606-016-3886-9
Simerly, G., & Blackhart, G. (2021). The eﬀects of self-care on undergraduate stress. The Undergraduate Journal of
Psychology, 32(1), 20–30. https://doi.org/10.1037/trm0000362
Skovholt, T. M., Grier, T. L., & Hanson, M. R. (2001). Career counseling for longevity: Self-care and burnout prevention
strategies for counselor resilience. Journal of Career Development, 27(3), 167–176. https://doi.org/10.1023/
A:1007830908587
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: theGAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Stamm, B. H. (2015). The concise ProQOL manual (2nd ed.). https://proqol.org/.
Tam, C. C., Ye, Z., Wang, Y., Li, X., & Lin, D. (2021). Self-care behaviors, drinking, and smoking to cope with psychologicaldistress during COVID-19 among Chinese college students: The role of resilience. Psychology & Health, 1–20. https://doi.org/10.1080/08870446.2021.2007913
Ullman, J. B., & Bentler, P. M. (2012). Structural equation modeling. Handbook of psychology. 2nd ed. John Wiley & Sons,
Inc.
Vindegaard, N., & Benros, M. E. (2020). COVID-19 pandemic and mental health consequences: Systematic review of thecurrent evidence. Brain, Behavior, and Immunity, 89, 531–542. https://doi.org/10.1016/j.bbi.2020.05.048
Wise, E. H., & Reuman, L. (2019). Promoting competent and ﬂourishing life-long practice for psychologists: A communitarian perspective. Professional Psychology: Research and Practice, 50(2), 129–135. https://doi.org/10.1037/
pro0000226