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Introduction
Training in clinical psychology and psychotherapy is a complex, gradual, and permanent learning process (Prado-Abril et al., 2017, 2019a) that includes formal aspects of study, participant observation, and supervised practice, as well as personal and interpersonal processes of the resident psychologist intern (PIR in Spanish) under the framework of a given historical, sociocultural, and autobiographical context. Furthermore, one of the distinctive features of psychotherapy is that it is articulated in the relationship between two people in the enclave represented by the therapeutic relationship (or alliance). This interpersonal nature and the fact that no two patients and no two therapists are alike endows psychotherapy with an unquestionable “craft” element in its strictest sense. That is, each psychotherapeutic process is unique and unrepeatable; it is tailor-made, ideographic, personal, and intersubjective (Fernández-Álvarez et al., 2020). Thus, training as a clinical psychologist in our country, among other aspects, also involves a certain element of tailoring, whereby all the agents involved, such as teaching committees, specialty tutors, teaching collaborators, etc., should adapt to the person on the PIR who is beginning his or her residency.
Hereinafter, we will reflect on the complexity of training as a clinical psychologist in Spain, with special emphasis on the first steps as a resident in the Spanish National Health System (SNS in Spanish) and the personal challenges that this entails. An attempt will be made to explain some of the normative aspects of the training process, such as professional stress, the risk of emotional burnout, and the ethical imperative of self-care, with the aim of normalizing them and placing them at the core of the training process (Gimeno-Peón et al., 2023). Likewise, a number of recommendations will be outlined for balancing the professional and personal demands of clinical psychology and psychotherapy practice, while the professional tries to take care of him/herself as a person or simply tries to survive (Randall, 2019).
Training in Clinical Psychology in Spain
In our country, clinical psychology is legally regulated in a manner equivalent to the other health specialties established via Specialized Health Training (FSE in Spanish), allowing access to the title of psychologist specialized in clinical psychology and the exercise of the competencies inherent to this specialty (Prado-Abril et al., 2019b). The FSE aims to provide residents with the knowledge, techniques, skills, and attitudes inherent to their corresponding discipline, simultaneously with the progressive assumption of responsibilities inherent to practicing it autonomously. Moreover, it is programmed and supervised work experience that guarantees the rights of professionals as workers, while they complete placements or training periods in different units (rotations) that allow them to obtain a global vision of the SNS, the multidisciplinary work, and an in-depth knowledge of the field of professional practice. It also guarantees patient safety since the teaching supervisor assumes responsibility for the first and successive steps of the PIR (Prado-Abril et al., 2019b).
The creation of the specialty in clinical psychology was an achievement for the whole of psychology that strengthened the role of the psychologist in the SNS, giving him/her the highest professional category and responsibility established by the condition of Area Specialist. This was a substantial milestone in a hegemonically biomedical trajectory and context. The progressive consolidation of clinical psychology as a standardized specialty with stable growth, although not without turbulence, can be confirmed in the recent public offer of 231 PIR places for access in 2023 (Order SND/840/2022). Whilst not taking the figure for granted, the upward trend of both PIR places and specialists in the SNS cannot be ignored when comparing their relative position with respect to the rest of the predominantly medical specialties (Fernández-García, 2021).
The PIR Residence
There are few published data on the personal characteristics and processes involved in obtaining a PIR position. Among the exceptions, the survey by Carreras and Morilla (2010) stands out, in which a representative sample—of candidates who obtained a place in 2010—was asked about what factors they associated with the result of the exam and obtaining a place on the PIR. The most frequently mentioned emerging category was "effort", which included aspects such as "persistence", "perseverance", or "study", together with the category "study technique or academy". Likewise, the study indicates an average of between two and three attempts to obtain a position. These results emphasize the demands and difficulties involved in accessing PIR specialized health training. It does not seem unreasonable to point out that the demands and risks to personal integrity of the process do not end with the access to a PIR position. In fact, they continue during the residency and throughout the professional career shaping a certain character or sense of identity in residents and future clinical psychologists (Prado-Abril et al., 2017).
The beginning of the PIR residency is usually a turning point in the life and autobiographical trajectory of the residents. For many of them it represents the first work experience or, at least, the first professional experience in the field of mental health after a multipurpose academic training, not focused on the field and with little practical preparation. Added to this are the complexity and apparent chaos involved in the SNS as a work context, the possibility of geographical displacement, the difficulties of access to housing, moving away from the usual social support networks, etc. In short, it is a highly stressful process. Over the four years involved in the training process via PIR, residents will assume responsibilities and gain autonomy in an increasing and progressive manner under the supervision of supervisors and teachers. The clinic involves contact with the suffering, misery, and pain of human beings that will inevitably awaken personal, professional, and existential insecurities in a context of need for validation as professionals and of life transition where the key lies in the support and learning with peers and supervisors of different care units that, additionally, will present varied and broad theoretical-technical perspectives (Areas et al., 2022; Pastor Morales & del Río Sánchez, 2018, 2022).
When residents settle into their teaching unit, as in any maturation process, they will gradually become aware that the reality often does not meet their expectations. Among other things, they will see that the supervision does not always meet their needs; that the institution sometimes pushes them to assume responsibilities that do not correspond to them; that there is not always a deliberate effort to care for professionals; that patients do not receive care under ideal conditions; that the formal and informal dynamics of multidisciplinary teams are complex; and they may even feel lonely and helpless during the process (ANPIR, 2022; Uhrig, 2021). It is possible that many specialists in clinical psychology have —at some time during their training process— felt some of the issues described above, having to grieve in order to readjust their expectations. This is a process of considerable emotional intensity that should be formally supervised and contemplated within the training process. In a certain sense, the very nature of the PIR residency consists of a concatenation of rotations where, when one adapts and feels comfortable, it necessarily comes to an end only to start all over again. A relentless grieving. A constant learning to say goodbye, for which it is particularly important to talk explicitly about how residents are cared for and how their self-care is encouraged.
The Importance of Self-Care
Regarding therapist self-care, it is no secret that on many occasions clinicians do not lead by example (see Gimeno-Peón et al., 2023 for an exhaustive review). The very pace of life in contemporary Western societies, with structural stress and multitasking as hallmarks, does not exactly invite us to incorporate into our lives some of the aspects that we specifically work on to improve the health of our patients. Committing to this profession requires significant effort and energy, which predisposes practitioners to an increased risk of stress (El-Ghoroury et al., 2012; Garrido-Macías et al., 2022) burnout, and professional deterioration (Harrison & Westwood, 2009). Paradoxically, the more patients are helped to move toward wellness, the more likely the clinician is to overlook his or her own needs (Barnett et al., 2007). In contrast, increased practice of self-care strategies has been found to be associated with greater satisfaction with professional and personal life (Garrido-Macías et al., 2022)..
During the PIR residency, after having overcome a high intensity process focused on a specific goal, a stage begins where it is necessary to develop a great flexibility to adapt and learn the singularities of each of the health care units through which they rotate, together with a weekly working day that exceeds 40 hours of exclusive dedication, when shifts and afternoons of continuous service are added. Likewise, a significant percentage of residents, in their free time, choose to undertake postgraduate training in various fields, start their doctorates, or even take on both tasks. The hours of work and training sometimes rise to over 50 hours per week. Of course, they read up on the state of the art in the field, prepare clinical sessions, organize part of their theoretical training, attend congresses, present papers, etc. High standards and excellence are taken for granted. The potential associated risks are barely questioned or reviewed.
As the months go by, residents may begin to experience the tension, restlessness, nerves, or anguish of working for the first time with patients in the SNS who often present complex clinical conditions that are difficult to manage. They also have to deal with the discovery that real practice is often far removed from the theoretical content they learned in their degree and in the competitive examination phase for access to the PIR. With experience, increased reflective capacity, and adequate supervision, they learn to listen slowly and in detail to people, prioritizing relational aspects over technical aspects that standardize and reduce (not always accurately) the complexity of people's mental health problems (Fernández-Álvarez et al., 2020; Mahoney, 1991; Truijens et al., 2019). At this stage, learning to perform ethically grounded psychotherapeutic interventions will entail understanding and recognizing the patient, integrating the synchronic with the diachronic, through a relational experience that helps patients to overcome their disturbing experiences while respecting their idiosyncrasies, values, and preferences. Finally, they will have to learn this craft and the art of its implementation in an environment and context that is eminently biomedical and hostile to the framework, principles, and timing of clinical psychology, psychotherapy, and the processes of human change (Deacon, 2013). Consequently, issues consubstantial to the practice of clinical psychology will emerge sooner rather than later, such as the need for supervision that is not always available or satisfactory, their own vulnerability, or questioning—in a more or less radical way—of central and nuclear aspects of their way of being and of being in the world (Mahoney, 1991).
To recapitulate, and following Skovholt and Trotter-Mathison (2010), it can be considered that this profession, in a significant part, consists of the ongoing construction of multifaceted therapeutic relationships with an endless number of patients. As the authors aptly point out, this basic aspect of practice demands of clinicians an ongoing accommodation of both emotional and personal involvement, setting boundaries, calibrating multiple variables, and with specific person-to-person sensitivity. Establishing and maintaining these working relationships requires significant effort and energy that, when sustained over time, can represent high professional stress that can lead to burnout and professional deterioration. As Barnett et al. (2007) and Norcross and VandenBos (2021) point out, paradoxically, the more you help patients, the more you work and, therefore, the more likely it is for clinicians to neglect their own self-care. In short, including an explicit chapter on self-care in PIR specialized health training is a pending issue in our country. It should not be forgotten that in clinical psychology the technology is the actual person of the practitioner, and that ensuring one is in optimal conditions to attend to patients is not only advisable in order to avoid professional burnout but also a responsibility and an ethical imperative for the patients.
Self-Care Domains
Given that the interest of this work, rather than theoretical, is decidedly didactic and pragmatic for the purpose of outlining a simple guide to self-care for residents, we will follow the results of the literature review conducted by Posluns and Gall (2020) who synthesize the challenge of self-care into six main components (see Figure 1). A summary of the self-care domains adapted to the needs of PIR specialized health training can be seen in Table 1.
Table 1. Domains of self-care and possible strategies during residency.
| Domain | Implications | Strategies |
|---|---|---|
| Self-awareness | Understanding the privileges and risks of being a mental health professional, adjusting expectations, reflecting on difficult experiences, monitoring one's own needs |
Express and share difficulties with peers Seek and request supervisory spaces Organize group activities such as Balint or DART in the teaching spaces. Consider personal psychotherapy |
| Balance | Adequately distributing the time dedicated to personal and professional aspects |
Perform activities not related to clinical psychology Plan breaks and vacations Spend time with family and friends |
| Flexibility |
Adaptation to the complexity and work dynamics of the SNS, to unforeseen events, inconsistencies, frustrations and disappointments Adaptive perfectionism |
Set limits if excessive responsibilities are received Learn to say no with assertiveness Initiate stimulatig projects Accept that the world is not fair |
| Physical health | Well-being and body care, healthy habits | Take care of hygiene, sleep, food, exercise, check health status, do not work when sick, rest |
| Social support | Close relationships with people in the personal and work environment who provide appreciation and positive appraisal |
Ask for help Accept help from others Cultivate personal and professional relationships Join an association, participate in a community |
| Values and meaning |
Sense of consistency Noble values Prosocial behavior |
Cultivate introspection Establish an individual and collective commitment Be compassionate towards one's own mistakes and shortcomings and to those of others |
Note.DART = “Difficulties in Acquiring Role of Therapist” Group (Bolado, 2018).
Self-awareness
Residency, when it is a meaningful process, involves a painful realization of our own limitations as individuals. However, at the same time, it is also an opportunity to explore some of our zones of proximal development with a certain margin of safety. We agree with Barnett et al. (2007) that it is during the first steps of the training process as specialists that residents should be encouraged to be especially aware of their own vulnerability, of the emotions aroused by working with patients in extremely serious situations, of the dynamics surrounding multi-professional work, and the associated stress. It is a matter of learning to look and listen in order to be able to register what one feels and to put it into words in order to build the habit of internal self-monitoring. Only if residents learn to detect the signs of risk will they be able to set up prevention mechanisms in time. The more aware a professional is of their needs, the more likely they are to recognize and address them (Norcross & VandenBos, 2021).
Balance
Distributing attention, energy, and dedication to various aspects of life by building a polyhedral existence or, at the very least, not neglecting basic aspects of daily life such as friends, family, and time to disconnect from a sometimes overwhelming job. Perhaps residency can be approached as four years to squeeze the most out of, but allocating more than 40 hours a week, sometimes 50, is not a habit that can be sustained for many years without consequences. The empirical literature on this is compelling. For a clinician to tolerate and manage the vicissitudes of a relatively intense daily clinical practice, avoiding the intoxication of the hardest part of the job, there need to be spaces where he or she cares in a different way, is cared for, breathes, or simply forgets that he or she is a clinical psychologist (Skovholt & Trotter-Mathison, 2010).
Flexibility
The PIR residency, with few exceptions, is a process of such emotional intensity that it will test the residents' capacity for adaptation to the limit, especially if they do not have adequate supervision and institutional support. Some data obtained with the NEO PI-R™ questionnaire, not published but advanced by Carreras (2022), indicate that the personality of PIR candidates who obtain a place, in general terms, is characterized by high scores in responsibility, in the facets related to perfectionism, and by a noteworthy tolerance to frustration. Incentivizing and encouraging the moderation of these performance tendencies may be very healthy for dealing effectively with the inconveniences and inconsistencies that occur daily in the SNS. Adaptive perfectionism, for example, involves accepting that mistakes and doubts are part of any learning process, that the important thing is the process, not the immediate result, and that the achievement of long-term goals involves resting and taking care of oneself. Perfectionism, on the other hand, can be maladaptive when it is rigidly oriented towards control or it covers the need to hide one's imperfections because it can hinder the natural process of making contact with one's own insecurity, vulnerability, or painful personal experiences that are inevitably activated when working with human suffering. Consequently, it can increase and maintain the emotional distress related to the residency (Thomas & Bigatti, 2020).
Physical Health
Any chapter of primary prevention includes among its recommendations the importance of healthy lifestyle habits covering aspects related to overall health care, such as maintaining minimum levels of hygiene, sleep, rest, food, exercise, etc. Yet it is not clear how many hours a week mental health professionals spend on these activities (Gimeno-Peón et al., 2023; Norcross & VandenBos, 2021). However, when practitioners with a long career history are questioned, they clearly indicate that maintaining a healthy lifestyle constitutes one of the pillars of their self-care (Thériault et al., 2015).
Social Support
Like any human being, clinicians and especially residents need different sources of support, both personal and professional, that provide self-esteem and a positive sense of self. This point, in part, ties in with the domain of balance in terms of moderately calibrating sources of personal and professional social support. With regard to aspects related to the residency, the supervision of teaching collaborators, the figure of the tutor, and institutional support should all play an essential role here. However, our daily experience confirms—in convergence with the findings of the study by Thériault et al. (2015)—that perhaps the key factor is played by peers. Residents often form informal networks of mutual support, both within their own specialty and outside it, with other specialists in training, which serve as a space for accompaniment, emotional support, and peer supervision that ultimately contain and protect them from the stress associated with the process. It would perhaps be interesting to address and direct this natural process associated with the residency in an explicit way within the teaching spaces in group format, such as those focused on the Difficulties in Acquiring the Role of Therapist (DART; Bolado, 2018). Similarly, it is important to take care of these mutual support networks instead of favoring other dynamics related to peer competitiveness that may occur in highly demanding environments. In this context, the equanimous and equidistant role of tutors and teaching supervisors with respect to all their supervisees can act as a guarantor of equal access to the same opportunities. At this stage, they should stay away from dual or extraprofessional relationships that could favor or be interpreted as sympathies that would disregard the professional merit and ability (Pastor Morales & del Río Sánchez, 2018). Finally, participating in a community or getting involved in a professional association can facilitate contact with peers, reducing the risk of isolation and the feeling of loneliness, to create collective systems that serve as an umbrella for the containment of troubles derived from professional and organizational challenges (Posluns & Gall, 2020).
Values and Meaning
Perhaps one of the great challenges for residents in the specialty of clinical psychology throughout the four years of FSE is to find a certain sense of coherence articulated in certain values and behaviors that, in our context, are part of a collective heritage that now has 25 years of official history (Royal Decree 2490/1998). Noble values such as the defense of the public sector, the priority of the rights of vulnerable people, the importance of multidisciplinary work versus corporatism, the preponderance of the collective over the individual, as well as the ethical and professional behaviors that derive from positioning oneself in this way, may be difficult to understand or assimilate in the current SNS which, due to more than a decade of cutbacks and the recent social and healthcare crisis, is at the worst moment in its history. It may even be at risk of being progressively dismantled over the coming decades (Lamata & Pérez, 2011). In this context, perhaps participating in the values and meanings that led to universal public health care and an FSE system of excellence could be an antidote to the suffering generated by the drift of our health care model. Basically, what is at stake is whether we adequately train specialists in clinical psychology who, with their knowledge, skills, and attitudes, situate themselves in an open constructive disposition in the health and social context in which they must participate responsibly to improve the health care of the population and of the SNS (Olabarría & García, 2011). Obviously, there may be other values, meanings, and behaviors that serve to find a sense of personal coherence that protects the health of the professional, but our proposal is to participate in a historical and collective process that transcends the individual.
Discussion
Resident psychologists are specialists in training who, to a large extent, will be the specialists in clinical psychology that will serve citizens over the coming decades with an SNS designed to guarantee their right to receive specialized health care of the highest quality (Law 14/1986). Consequently, caring for them with the highest standards of quality and affection is not only an intelligent and sensible policy, but also represents a clear investment in the resilience of the system and in the mental health care of Spanish people (Ministerio de Sanidad [Ministry of Health], 2022a). Currently, most FSE programs are subject to review and updating by the national commissions of the respective specialties under the coordination of the General Directorate of Professional Management of the Spanish Ministry of Health. Therefore, practicing conscious and deliberate self-care is our ethical duty, if we want to continue to be able to provide the best possible treatment to our patients. For their part, the institutions should help and facilitate substantial improvements to the future training program of the specialty in clinical psychology—as well as updating its duration to 5 years—establishing a program where self-care and empirical knowledge on the development of the practice of psychotherapy are present throughout the program. Likewise, this program should establish the organizational mechanisms and guarantees that are necessary for the program to be implemented in the daily reality of the SNS.
At this precise moment, given the agenda established by the Ministry of Health in relation to mental health (Ministerio de Sanidad [Ministry of Health], 2022b), the planning and systematization of those formal and informal spaces that during residency contribute to cultivate the attitudes, competencies, and behaviors associated with the self-care of residents with the aim of facilitating satisfactory, functional, and lasting professional careers over time is of particular importance. Throughout this text, some of the main targets have been outlined regarding what a training program that cares and teaches self-care could look like. Without being exhaustive, we should be aware of our own needs, of the difficulty of working with vulnerable people or those with high levels of psychopathological disturbance, of the relevance of self-monitoring of the general state of health, of the balance between the personal and the professional, of the importance of working on flexibility and the ability to adapt to changing environments, and of the orientation towards joining an association and the development of a sense of community that protects one from the isolation and loneliness that is intrinsic to this profession. Without forgetting that residency involves an identity process in which each person tries to find a personal meaning that balances his or her own principles, values, and ideals with the collective ethos that permeates the specialty. The residency is, in fact, an unrepeatable environment for cultivating introspection, learning from mistakes, sharing difficulties, gaining relational security, and getting involved in stimulating projects; that is, implementing self-care strategies if these are encouraged, taught, and facilitated. Providing spaces and opportunities for care in the training process and redefining self-care as an unavoidable learning need will not only allow residents to survive a period of considerable intensity, but also to become specialists that are more capable of helping patients, colleagues, and residents. There is enough empirical evidence and significant accumulated clinical knowledge to avoid leaving this chapter to chance, on the informal level, without ordering and structuring it in an adequate manner.
However, it is of little use to teach how to detect needs and to ask for help if there is not a reliable response adjusted to those needs. The role of the FSE tutor and teaching supervisors is of a transcendence that is not always taken into consideration or valued in its full dimension. Tutors and supervisors are the reference figures for residents and, consequently, the first example to be followed. If they take care of themselves and take good care of the residents that may be the best modeling available. They are partly responsible for fostering friendly, egalitarian, and non-competitive environments, overseeing relational dynamics, promoting reasonable schedules, and ensuring time for rest. Perhaps tutors and teaching supervisors should be required to have a higher curriculum for their accreditation and performance, but they should also be provided with real spaces, outside the healthcare agenda, for the supervision and teaching of residents. It cannot be ignored that the available information indicates that 54% of residents say that the supervision they receive is not sufficient or of the desired quality and that 32% directly underline that there are no formal spaces for supervision (ANPIR, 2022; Uhrig, 2021). The day-to-day dynamics, characterized by the collapse and overload of care in the SNS, cannot justify informal or “corridor” supervision. Improvement is non-negotiable and there is certainly no greater consensus among residents than that regarding the need to improve group teaching spaces and supervision.
In conclusion, the specialty in clinical psychology was a milestone for all psychology in this country and, now that it is 25 years old, with the updating of its training program currently under consideration, it deserves a rethinking in order to improve its social function and vocation of public service. Educating trainee specialists in caring for themselves in order to care for others, as well as in the best evidence-based health technologies, will surely serve to complete another 25 years of service to the community in good health. Likewise, it will provide the SNS with specialists who are sensitive to the needs of residents and perhaps establish a much-needed cycle of care in stormy times such as the ones we are currently experiencing.
