Introduction

Clinical psychologists and psychotherapists face challenges that affect their well-being (Barton, 2020;Figley, 2002) contributing to the occurrence of sleep problems, depression, anxiety, emotional exhaustion, amongst others (Barton, 2020; Pope & Tabachnick, 1994).

Therapists put their energy toward patients, attending to their needs and listening to their suffering (Figley, 2002; Norcross & VandenBos, 2018), but need also to regulate their own feelings to avoid compromising the therapeutic relationship (Spiegel, 1990). Working conditions, such as work overload, the experience of feelings of injustice or helplessness, lack of control in job policies or lack of acknowledgement are additional stressors (Killian, 2008; Norcross & VandenBos, 2018; Turnbull & Rhodes, 2019). Moreover, younger and less experienced psychologists seem to be more predisposed to have stress-related problems (Simionato & Simpson, 2018).

Working in a palliative care

In palliative care settings, the goal is not to cure the disease or prolong patients’ life, but to give patients a good quality of life, minimize their suffering and contribute to a peaceful death (Pereira et al., 2014). Psychologists’ roles include: (a) intervention and support on the patient and family; (b) grief and loss intervention on the patient’s family; and (c) support of palliative care team members, ideally provided by a psychologist outside the team (Ordem dos Psicólogos Potugueses, 2019).

Risk factors

Despite the lack of research on the risks palliative care psychologists are exposed to, these are well studied on other palliative care practitioners (Kavalieratos et al., 2017; Pereira et al., 2014; Rockach, 2005). Some factors that may contribute to high levels of stress in palliative care workers are: the contact with anger, grief and despair of the patients and their families; the exposure to patients’ suffering and death; and having to cope with the medical impossibility to treat them (Rockach, 2005). Several studies mentioned other risks which impact nurses and physicians, as: lack of boundaries (White et al., 2004); feeling that one is not making a difference; having high self-judgement (Kavalieratos et al., 2017); feelings of failure, frustration and impotence (White et al., 2004); role monotony (Kavalieratos et al., 2017); work overload and feeling overwhelmed (Graham et al., 1996; Kavalieratos et al., 2017).

Regarding palliative care psychologists, organizational changes seem to compromise their well-being the most. Moreover, the beliefs that psychologists can contain and tolerate their emotions, as well as that they should be able to support the team may hinder the expression of their emotions, contributing to the experience of professional exhaustion (Cramond et al., 2020).

Rewards and protective factors

Although palliative care professionals face several risks, the prevalence of burnout in these professionals is low compared to professionals working in other settings (García et al., 2009; Pereira et al, 2014; Pereira et al., 2016). A possible reason is that they are able to balance the risks with the benefits of working in this context (Barbosa et al., 2014; Prada-Ospina, 2019).

Compassion satisfaction is a sense of accomplishment and reward resulting from caring for others in suffering, in which the professional feels capable of making a positive difference in helping others (Barbosa et al., 2014; Stamm, 2005). Some studies have shown negative correlations between compassion satisfaction and compassion fatigue or burnout in palliative care professionals (Kase et al., 2019; Sansó et al., 2015).

Having a sense of control and commitment over events (Frey et al., 2018), good relationships with patients and families (Graham et al., 1996), the presence of teamwork, communication skills (Kearney et al., 2009), and palliative care education (Frey et al., 2018; Kearney et al., 2009) may also prevent stress-related problems. Furthermore, coping with death and being able to give a meaning to the end of life seems to influence the ability to work in this setting without feeling overwhelmed by the suffering of the patients (Pereira et al., 2016; Sansó et al., 2015).

Psychologists working in this setting described their job has a privilege and felt the gains outweighed the costs. Albeit their emotional involvement with their patients, they reported having the ability to create distance between themselves and patients. Working in this setting also seems to change the psychologist as a person, since being exposed to death allows for a reflection about life and an acceptance of its unpredictability (Cramond et al., 2020).

Self-care

Self-care refers to the activities that one does to promote their physical and emotional well-being and, consequently, to assure effective professional performance (Wise & Reuman, 2019). By taking care of themselves, psychologists become more capable of dealing with challenging interpersonal contexts (Wise & Reuman, 2019), feel better (Rupert & Dorociak, 2019; Wise et al., 2012), and take better care of others (Norcross & VandenBos, 2018). Since there is a tendency for psychologists to ignore signals of stress and not to spend time taking care of themselves (Norcross & VandenBos, 2018; Skovholt & Trotter-Mathison, 2016), it is necessary to create a culture of self-care by preparing them for the challenges inherent to the job (Barnett & Cooper, 2009).

Strategies

Even though the choice of self-care strategies is idiosyncratic, several studies identified strategies used by psychologists (Harrison & Westwood, 2009; Killian, 2008). Those include maintaining a healthy lifestyle, spending quality time with friends and family, practicing pleasurable activities, using sense of humour, managing personal time, continuous education, and having supervision.

Self-care strategies in palliative care

Some strategies engaged by palliative care physicians and nurses are: healthy eating, relaxing, spiritual practice, talking to others, and using sense of humour (Mills et al., 2018; Swetz et al., 2009). Beyond those, in the only study that focuses on the self-care of psychologists working in palliative care, psychologists also reported making personal use of psychological interventions, having supervision, monitoring stress responses, using grounding techniques and switching off from patients after sessions (Cramond et al., 2020).

Barriers

Usually, psychologists are too busy taking care of others, focusing on time-frame requirements, doing paperwork, amongst other things that hampers the prioritization of themselves. Moreover, they tend to believe that it would be selfish to spend time doing self-care (Norcross & VandenBos, 2018).

Research to date scarcely mentions barriers to self-care in palliative care setting, especially regarding clinical psychologists. However, Mills et al. (2018) identified the impediments to self-care in palliative care nurses and doctors, namely: work overload, stigma related to self-care, self-criticism and low self-worth, and lack of self-care planning.

Purpose of study

Given the lack of studies on the psychosocial risks that clinical psychologists working in palliative care are exposed to, as well as on their self-care strategies, there is a need to understand the impact this setting has on professional performance and on their self-care. The goal of this study was to explore the experiences of clinical psychologists working in palliative care in an attempt to better understand their self-care practices. Concretely, this study seeks to: (1) explore the experiences of clinical psychologists working in palliative care setting, (2) understand the role of self-care in the experiences of working in palliative care, (3) explore the relevance psychologists attribute to self-care training.

Method

Design

Considering the need to explore the experience of palliative care psychologists and the impact their job has on themselves as a person, including their self-care practices, a qualitative research design was employed. A semi-structured interview was conducted, and transcripts were explored using thematic analysis following the approach of Braun and Clarke (2006).

Participants

Eleven clinical psychologists working in palliative care participated in this study. Participants were all women and their age ranged between 30 and 64 (M = 45.27; SD = 10.57). They worked in Lisbon (n = 8), Porto (n =1), Baixo Alentejo (n =1), and Ponta Delgada (n = 1). All participants had specialized training in palliative care, such as master’s degree in palliative care (n = 2), post-graduation in palliative care (n = 3), basic and intermediate training in palliative care (n = 4), training in grief and bereavement (n = 3), and several workshops about spirituality and the psychologist role in palliative care (n = 1). Participants had between five to 40 years of total working experience (M = 20.36; SD = 11.32) and between one to 10 years working in palliative care services (M = 4.27; SD = 3.20). They worked in different types of palliative care teams: four worked in a community team, three worked in in-patient wards, two worked in an intra-hospital supporting team and two worked in all the aforementioned. Most of the participants worked with adults (n = 9) and the remaining worked with children, teenagers, and adults. They spent between seven to 40 hours per week on palliative care service (M = 22.36; SD = 15.09). Weakly, psychologists followed up a mean of 14 cases (SD = 10.30; Max = 35; Min = 4). Data were anonymised by attributing numbers to the participants preceded by the letter “P” (e.g., P1).

Recruitment and data collection

The study was presented via email to the Portuguese Association of Palliative Care and through contact of the Palliative Care teams of the Portuguese Health National Service. Participants had to be clinical psychologists working in palliative care, full members of the Order of Portuguese Psychologists and have at least five years of clinical experience as qualified clinical psychologists. Psychologists interested in collaborating were asked to contact the research team by email or phone.

Written consent was obtained from all participants. Data collection took place between January and March 2022. Five interviews were conducted and audio-recorded face-to-face at a place chosen by participants, whilst six were conducted over videocall. Before the interview participants were asked to fill out a sociodemographic questionnaire. An interview guide was developed to address the study aim (Table 1). Interviews lasted between 10 to 35 minutes (M = 23.17; SD = 8.30).

Table 1.
Interview guide

Table 1.Interview guide

What are the risks, if any, of being a psychologist in palliative care setting?What are the benefits, if any, of being a psychologist in palliative care setting?How do you manage those risks and benefits in order to maintain your well-being?Have you ever experienced symptoms of professional exhaustion? If yes, how did it impact your life?During your training, how was the relevance of self-care approached?To what extend do you think is important to approach self-care topics during training?Do you spend time using self-care strategies? Can you give me some examples of the strategies you use?Tell me how the use of strategies changed in time. How do you think self-care strategies benefit you?What are the barriers to your self-care?

Data analysis

After transcription of the interviews, data was imported to QSR Nvivo 12 Pro software for coding. Data analysis was bottom-up and followed the six phases of thematic analysis, as proposed by Braun and Clarke (2006). First, the researcher familiarized with the data by transcribing, reading and re-reading it. Then, codes were generated from the experiences of participants within their answers, in which were organized into main themes according to their semantic similarities and differences. Themes were reviewed through the constant comparison between themes, codes and the entire data, resulting in a hierarchy coding system. At this point, data was refined, and names were given to the final themes considering the narratives they represent. A final analysis was made, relating the selected extracts to research goals and existing literature. To assure the reliability of the research, data was analysed by the first author and peer-reviewed by the second author. The third author worked as an external consultant of the analysis, as proposed by Lincoln and Guba (1985).

Quality control

The authors are clinical psychologists and psychotherapists who have been working in private practice and/or psychiatry contexts. None have worked in the palliative care setting. Also, they have experience in qualitative research, and one of the authors has been focusing on the study of self-care during the last years.

A field diary was used to facilitate the credibility of the research, allowing for a better awareness of researchers’ biases (Krefting, 1991). It was followed the criteria and guidelines proposed by Elliot et al. (1999) for the achievement of rigor in the methodology.

Results and discussion

Working in palliative care and its impact

This domain refers to the roles of clinical psychologists in palliative care settings and to the impact their job has on the psychologist as a person (goal 1).

The identity built from their professional roles

This theme portrays the diversity of psychologists’ interventions. Several participants mentioned that it is their job to take care of the team (7), stating “(…) when we know that there is a nurse who was impacted by a particular situation, psychologists are the ones that, most of the times, let the person speak about his experience, so he can vent his emotions” (P3). Also, by being in a context in which the death of patients is expected, some participants reported that one of their goals is to contribute to a peaceful death of patients (4). Also, grief intervention for patients’ family (3) was reported by some psychologists. The interventions stated are aligned with the roles of psychologists working in palliative care proposed by Ordem dos Psicólogos Portugueses (2019).

Threats to psychologists’ well-being

The category work threats (9) illustrates features inherent to the job of psychologists that negatively impact their health and well-being. Most participants mentioned that the therapeutic relationship and emotional involvement (8) contribute to the attachment to the patients and difficulties coping with their loss: “(…) there are situations that affect us. It will always happen, won’t it? My job is very relational (…). We get to much involved in situations. And it is natural that it affects us, and that we have signals…” (P3). Consequently, due to the emotional involvement and empathy inherent to the therapeutic relationship, the exposure to human boundaries: illness, suffering and death (6) is constant in their lives. Some participants mentioned being “(…) always confronted with other’s fragility and finitude” (P2). This content is not new, since being exposed to death of the patients is one of the demands of being a palliative care worker (Rockach, 2005). Lastly, one participant mentioned “But then, there is no one taking care of us, right?” (P3). The allusion to the fact that no one takes care of us (1) suggests the absence of awareness from other professionals with regards to the need for taking care of the psychologist. Other possibilities are that psychologists may not be good in asking for help or may be seen mostly as helpers.

The category threats from personal life (7) includes: personal vulnerabilities (5) and being unexperienced (2). In general, participants described how their personal experiences can determine how they cope with their job. Having hard times in their personal lives, coupled with low resilience to deal with adversities, is a threat to psychologists’ well-being at work. Also, taking into account a gender perspective, as women have more responsibilities regarding domestic chores, they may experience a bigger impact of their personal life on their availability to care for others (Mon et al., 2018).

Considering working conditions (5), some participants referred to work overload and feeling overwhelmed (5): “I had moments in which I felt there was, in fact, a lot of pressure…of time, deadlines (…)” (P1). They also referred to the conflicts and disagreements between professionals (3): “(…) there is another factor I believe that also exists in other jobs, which is the presence of interpersonal conflicts. (…) Or disagreements (…)” (P8). Considering that the occurrence of conflicts between palliative care professionals contributes to the incidence of burnout in nurses and doctors (Pereira et al., 2014), data suggest this factor also affects psychologists.

Professional costs

When participants mentioned the negative consequences of their work, they referred to the emergence of physical and emotional symptoms. This includes physical and emotional exhaustion, and stress (7); increased risk of professional exhaustion (7): “(…) those symptoms didn´t exist in the beginning. In the beginning it is like when we fall in love, and we feel lots of energy and motivation… But, due to our age, or because of the amount of work we have, there is a bigger risk” (P4); sleeping problems (3); irritability and emotional lability (3); and emotional unavailability for the family (2). Those consequences are similar to those found in literature that mentions the negative effects of being a palliative care nurse or doctor (Acinas, 2012), as well as of being a clinical psychologist in general (Pope & Tabachnik, 1994). Despite Simionato and Simpson (2018) had shown that experienced psychologists had lower levels of stress than less experienced psychologists, participants mentioned having the perception of an increased predisposition for professional exhaustion as time goes by. They justified that as being a consequence of the cumulative effects of risk factors of being a help professional, which was previously mentioned by Caravaca-Sánchez et al. (2022) on their study with social worker professionals.

An opportunity to give meaning to life

This theme captured how this job has an existential impact on psychologists, helping them to attribute a meaningful sense to their lives. The most referred gain was the emergence of feelings of Compassion satisfaction (10) “I think it is one of the most gratifying jobs that we have (…). And that is very gratifying, what remains, the fact that they [the patient’s family] acknowledge us, (…), they still remember us. It is a huge gratification, I think…” (P3). Also, being exposed to the limits of human nature and to death everyday makes them question their own finitude and adopt an attitude of Carpe Diem: to value one’s life (5): “(…) this makes us question life and the instability of things, don’t you agree? And it gives focus to the present moment, and makes us want to live our days the best way possible, doesn’t it?” (P10). That seems to be related Cramond et al. (2020)’s findings, in which psychologists mentioned having an accepting attitude of the unpredictability of life. Some participants mentioned personal growth derived from work (4): “not only do we learn a lot with patients and their families, but also with the rest of the professionals” (P8). Being a psychologist in palliative care is also an opportunity to understand the power of man: to access human’s capacity to overcome adversities (2): “And the truth is that it is a discovery: the way human beings are capable of transcending themselves in moments that are so vulnerable (…) and to overcome it…” (P10).

These data suggest that the characteristics of working in this context, which sometimes have risks that compromise the well-being of psychologists, mostly have a positive existential impact on these professionals, determining the way they face life (Cramond et al., 2020; Kearney et al., 2009). Caring for others who are suffering seems to generate feelings of realization and reward in which psychologists believe they make a difference in helping others. That helps mitigating the impact of the negative consequences of their job (Kavalieratos et al., 2017).

Self-care: How, what for and why not more?

This domain describes several aspects related to self-care, namely: the relationship between working in palliative care and the use of self-care strategies and which factors hamper self-care (goal 2).

Palliative care as a chance to self-care

The theme depicts the way psychologists changed their self-care when they started working in palliative care. Several participants reported that after they had started working in palliative care, there was an intensification and awareness of the use of strategies (6): “(…) when I started my activity in this area, I felt this was something that had become urgent in terms of this need to self-discipline, of making it effectively happen, to create space for those moments in a more conscious way, more deliberate way (…)” (P10), while some mentioned the beginning of the use of self-care strategies (3): “I think the traumatic situation of that patient who died when I was there the first time…I think it affected me, alerted me. (…) That I need to be careful.” (P3). Several participants mentioned that they engaged with different strategies according to their felt needs (5). Even though psychologists know in theory that they should “practice what they preach”, the reality seems to be that they start being more aware of the need of self-care when they feel the impact of their work (Cramond, 2019).

How to take care of me?

This theme describes which self-care strategies are used by participants. Psychologists engaged in several and diverse strategies. Most psychologists mentioned that having leisure moments (10) contribute to their well-being by helping them appreciate other areas of their lives and turn off their mind from worries related to work. These moments include: listening to music (7); reading (5); watching movies (4); contacting with nature (3); amongst others.

The most referred strategy mentioned by most participants was to share challenges and difficulties with the team (10): “First, to try to debate with the team. Or when I figure out that (…) it could have been a difficult case, not only for me, but also for the others (…), to try to debate, to try to know what we could have done.” (P8). By sharing “(…) doubts, fears, hesitations, insecurities” (P8), they feel the support of the rest of the team and feel they are not alone in dealing with the challenges related to their work.

For being in a therapeutic relationship that expose psychologists to illness and death, made participants recognize life’s unpredictability. This makes them seize the present moment and, consequently, nourishing personal relationships (8): “And each day have to be seized…by giving value to what I have and, especially, to what is most important for me and for whom I live every day, which is the family.” (P1) and to valuing oneself (5). There seems to exist some characteristics related to their work that contribute to a creation of “(…) a compassionate tone, isn’t it? In relation to myself…” (P10), allowing psychologists to seek wellness and give value to important things in life. For instance, one participant mentioned “I started to look after me and to search for well-being, tranquillity (…), minimizing anxieties (…). And I don’t forget myself: Every day I remember myself, and that is really good. And it comes from the work I do here.” (P1). Also, several participants referred that it is important to mindfully manage the risks (7) so that they are aware of what is happening in their lives and prevent the occurrence of distress.

Participants felt the need to define boundaries (6) to prevent from being too emotionally involved with their patients’ history: “(…) We have to make a big effort (…) to separate what is ours from what is theirs [the clients]. (…). To put ourselves towards what we do, towards that person we have in front of us (…); to understand, to be aware of what is activated in ourselves (…)” (P10). Psychologists attempt to acknowledge that they have their own personal wounds and learn to “make a distance between what is professional and what is personal” (P9).

Other strategies that emerged were: practicing exercise (6); learning new knowledge (6) taking breaks (5); doing psychotherapy (3); having spiritual practice and doing meditation (4) taking vacations (3); breaking routines (3) and supervision (3).

Despite most strategies being used by several clinical psychologists in general (Harrison & Westwood, 2009; Killian, 2008; Skovholt & Trotter-Mathison, 2016; Swetz et al., 2009), participants emphasised some that may help them cope with the challenges of their job, as having pleasurable moments; sharing challenges and difficulties with the team; recognizing and managing the risks; nourishing personal relationships; and defining boundaries. These results are similar to studies which revealed the strategies most used by palliative care practitioners (Cramond et al., 2020; Mills et al., 2018).

Some other strategies mentioned seem to help prioritize the personal self, as to break routines and to value oneself. Considering that the ability to take care of the other is a crucial part of the psychologists’ routine, it is important to spend a few moments alone, learning to relate to themselves and feeling self-compassionate. Participants seemed to learn to be kinder and more compassionate to themselves, embracing their vulnerabilities. This process allows them to be able to forgive themselves and accept that the human experience includes some imperfection (Skovholt & Trotter-Mathison, 2016).

Why taking care of me?

Every psychologist considered taking care of themselves indispensable to feel better: to have health and well-being (11): “[self-care strategies] bring happiness. If we feel happy, we can work better, we live better, we relate better with others, we have quality of life and we feel will to live, to do more and better.” (P1). For most participants, self-care strategies help them build healthy relationships with others. Regarding their job, they have a sense that they take better care: to assure an effective practice (9): “If we don’t take care of us, we can’t work well, we can´t take care of others and help others too.” (P3). Also, by caring about themselves and reducing the negative impact of their work experiences, they increased their availability for personal life (5): “It is important for people to attend to themselves. (…) For us to be capable of relating to the others and to love them, we should feel available for that. We should be available for recognizing and giving love” (P1).

In general, participants spoke about how their investment in self-care contributes to their growth and resilience, including helping them to manage emotions (3) and not to leave loose ends: integrate the experiences of their patients (3), which enables a “(…) closure of the clinical cases.” (P8). This benefit seems to be specific to the palliative care context. Psychologists need to integrate the voluntary end of the clinical process. As mentioned by Skovholt and Trotter-Mathison (2016), the ability to honour losses facilitates the separation between therapist and patient and, consequently, allows the therapist to feel capable of establishing new relationships. In contrast to other settings, in palliative care settings the end of the therapeutic relationship with the patient happens when the patient dies, and psychologists need to do their own grieving process. By being able to cope with the end of life of their patients, psychologists can maintain their job in this context as well as their well-being (Pereira et al., 2016; Sansó et al., 2015).

What hinders me to self-care?

The majority of participants identified obstacles to self-care related to lack of time due to excess of work (8): “The obstacles are the excessive amount of working hours in these areas, without enough mental health professionals to respond.” (P4). Psychologists recognize moments where they need to self-care, however, as they feel pressured to accomplish their duties, they have difficulties in taking breaks during the day. “We recognize we need to stop and do something that help us feeling better. However, most of the times we keep working. And we have so much work to do, that we don’t stop to integrate the experiences” (P3). The lack of time due to overload was also identified by palliative care nurses and doctors (Mills et al., 2018). Moreover, this is in line with previous studies which mentioned that psychologists’ self-care was affected by the demand to do their best with few resources (Cramond et al., 2020).

Several participants referred to some factors related to the person (8) as to find themselves undefeated: resistance to accept the need of self-care (6): “Sometimes I forget. Obviously, we sometimes forget about ourselves (…). The others are the ones who need us, we do not need (…)” (P5); and to find excuses (2). Another participant noted feelings of guilt about self-caring (1), saying, “We, in fact, don´t have a culture of self-care. We often feel very guilty when we spend time by ourselves.” (P10). These data mirror how psychologists believe that they should be able to regulate and tolerate every level of stress and unpleasurable emotions (Cramond et al., 2020). In general, participants showed difficulties acknowledging that “(…) we are in a phase of more fragility and, so, in need of more care.” (P2).

This data seems to be contrary to the idea of participants respecting their needs and being self-compassionate mentioned above. On the one hand, participants started to cultivate the relationship with their inner self and with their loved ones, as they allowed themselves to seize moments outside the workplace. On the other, there also seems to exist expectations about psychologists’ roles that motivate them to ignore their needs. As being help professionals, what they give to others may be more rewarding than caring for themselves. These reinforces the importance of creating a self-care culture (Barnett & Cooper, 2009). By learning about the importance of self-care and having an increased awareness about their beliefs, psychologists may start doing what they need to feel good and help better.

Lastly, a few psychologists pointed that living far away from supervision or therapy (2) impedes the access to and searching for these services. By having supervision and doing psychotherapy, they might feel supported and confident when doing their job, as it is of major importance for the continuous growth and development of psychologists, as professionals and as a person (Norcross & VandenBos, 2018).

What moves me to self-care

This theme reflects the factors that contribute to the promotion of self-care practices. Several psychologists mentioned feeling a duty to take care of oneself (6), stating, for example “And maybe the recognition (…), the recognition of the need, right? I think if there is that recognition of the need, everything is easier afterwards.” (P11). According to Barnett and Cooper (2009), it is an ethical responsibility to feel well to be able to care of others. A few participants mentioned that training on grieving (3) “motivated self-knowledge and self-care.” (P9). Some noted that they seek self-care strategies when the emergence of stress symptoms (3) occurs. As witnessed by one participant “There are moments in which I feel they [symptoms] are arising, and then I keep alert, and I try to find those strategies.” (P2). Having the need to own time for oneself (2) was also claimed.

Self-care learning

This last domain illustrates how psychologists acquired the knowledge about self-care. It allows us to understand whether self-care was mentioned during their education, capturing the relevance given to that topic (goal 3).

Access to information

The theme indicates whether participants had access to information about self-care during their training. Most participants noted having little access to information on academic and professional training (10), stating, for example, “I think it is a very ignored area, even in academic education and, even after, in terms of our practice (…)” (P3). These results are not surprising given the little relevance attributed to self-care (Barnett & Cooper, 2009) during the education of psychologists. Considering the little education given about this topic, a few participants mentioned they had been encouraged to take care of themselves when they received training on grieving (2) and others did a proactive search (3). Only one participant mentioned having had access to information about self-care during academic education and congresses (1). Since she is the youngest and less experienced participant, it is possible this topic has been recently included in the curriculum.

Educating self-care

Most participants attributed relevance to the education of self-care during academic and professional journey, considering that it allows: to acquire knowledge and skills to manage the impact of their job (7): “Maybe to give us the tools to be ready. So, we are not unprepared for the world of constant suffering.” (P5); and to make self-care conscient (3): “Of course education is essential (…) [for] people to realise that [self-care] is important. Because we sometimes are in automatic mode, doing what we have to do (…) (P8). Psychologists believe that there is lack of awareness of the impact their job has on themselves, ignoring their worries and pains. As a participant said “There should be a moment in our training where they tell us ‘This is also part of your worries for the future. You don’t have to only worry about the other, you have to worry about yourself too’”. By having the knowledge about this topic, we hope psychologists become more aware about the impact their job has on their well-being, increasing responsibility for themselves and for others (Barnett & Cooper, 2009; Norcross & VandenBos, 2018).

Conclusion

The results of the study may allow a better understanding of the impact that palliative care context has on psychologists’ well-being and self-care. Despite there being risks related to psychologists’ roles, the gains have a major influence on their well-being and contribute to their growth as an individual. The context in which they work seems to influence the frequency and type of strategies they engage with, but also the relevance they attribute to self-care. With the beginning of their work in palliative care, several psychologists started to practice self-care or intensified the strategies. As so, working in this context can be seen as a turning point for psychologists caring about themselves.

The strategies that emerged from participants do not seem to be specific to palliative care context. However, several strategies were mentioned more frequently by most of the participants. We hypothesize that, given the existential impact that palliative care setting has on psychologists, they may prioritize strategies that enhance their relationships with themselves and with their significant ones. Overall, working in palliative care contributes to the appreciation of psychologists’ lives, impacting the way they give meaning to their daily experiences.

Regarding barriers to self-care, lack of time due to work overload was the most highlighted obstacle. Also, the fact psychologists find themselves undefeated, denying this need to take care of themselves is a barrier to self-care. A possible explanation for this is that psychologists seem to have biased beliefs about what is expected from them as mental health professionals. It is common for psychologists to think that taking time for themselves instead of being with their patients is a selfish behaviour (Norcross & VandenBos, 2018). Also, psychologists perceive that other professionals see them as a model who can perfectly manage their emotions and vulnerabilities (Cramond et al., 2020). It may be that these barriers are related to little access to information about self-care during their training, since most participants identified the need to invest on self-care education.

It seems that it is the exposure to suffering, which is inherent to the practice of clinical psychology as a whole, that has a major impact on psychologist’s well-being and, consequently, on their need to engage in self-care. Regarding self-care, it may not make sense to differentiate between psychologists working in different areas but, instead, to reflect about the common variables inherent to psychology practice as one.

Using thematic analysis allowed a broad and detailed understanding of a barely explored theme. Also, participants were open to share their experiences, which was reflected in the rapport established during the interviews. Perhaps that happened due to the relevance participants attributed to this theme. There were no differences in the rapport established in face-to-face interviews compared to online interviews. Concerning the shortest interview, its duration did not affect the content since the participant’s speech was fluid and succinct.

A limitation of the study relates to the characteristics of the sample as all participants were women and most worked in Lisbon. Despite that representing the demography in the working class of psychologists in Portugal, where most of these professionals are women, future research should include a broader and more diverse sample. Also, questions regarding the impact of the gender on the results may be raised, considering that the attitudes of the participants regarding self-care may be related to being women.

The data was collected before the onset of the pandemic of Covid-19 in Portugal. The results may have been different if collected a few months later, considering the constraints inherent to the pandemic.

Future research should focus on the impact of the Covid-19 on clinical psychologists’ self-care. Moreover, it would be interesting to access psychologists bias about themselves and to understand whether they have an impact on their self-compassion and self-care practices. Also, given the relevance attributed to the role of the team and to the sharing of difficulties with colleagues, it would also be interesting to explore the characteristics of palliative care teams and their impact on the well-being of psychologists.

It is hoped that this investigation increases the relevance given to self-care by psychologists working in the palliative care settings. It is also expected encourages the creation of educative systems that highlight the importance of psychologists looking after themselves while taking care of others.

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