Final submission Gladstone Dissertation final draft embedded 1

A5( M$57,$/ A576 $1E))(&7,9( 6(/) &$5(35$&7,&( )25M(17$/ H($/7+ P52)(66,21$/6? A dissertation presented to the faculty of ANTIOCH UNIVERSITY SANTA BARBARA In partial fulfillment of the requirement For the degree of DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY By Jake Gladstone, PsyD April 2018 ARE MARTIAL ARTS AN EFFECTIVE SELFCARE PRACTICE FOR MENTAL HEALTH PROFESSIONALS? This dissertation, by Jacob Gladstone, has been approved by the committee members signed below who recommend that it be accepted by the faculty of Antioch University Santa Barbara in partial fulfillment of requirements for the degree of Doctor of Psychology in Clinical Psychology Dissertation Committee: _ Dr Brett Kia-Keating, Ed.D Chairperson Dr Dan Schwartz, Ph.D Second Faculty Dr Randy Wood, Ph.D External Expert ŝŝ Copyright 2018 By Jacob Gladstone, Psy.D Candidate ŝŝŝ Abstract The field of mental health presents a wide range of occupational challenges including but not limited to ethical issues, cultural competency and effective caseload management In addition, mental health professionals who provide psychotherapy face a variety of challenging cases which include complicated interpersonal problems and stories of trauma Due to the demands of their work, mental health professionals are exposed to traumatic experiences that may have a negative impact on their emotional, physical, and cognitive functioning (Portnoy, 2011) The challenges which mental health professionals face highlight the importance of effective self-care practices to reduce occupational stress There us a body of research suggesting that the various aspects of martial arts martial arts, including the meditative practices as well as the physical exercise, can reduce stress and increase self-efficacy among martial arts practitioners (Birdee, et al., 2009; Bourdreau & Koznak, 1984; Boullosa, et al., 2015; Hakan, Kassab & Lothes, 2013; Hashizume et al., 2008) To date, however, there is no specific research examining whether martial arts could serve as an effective self-care practice for mental health professionals It is important to discuss both the benefits and disadvantages of practicing a martial art for self-care This is a qualitative, phenomenological study designed to explore the lived experiences of mental health professionals who practice martial arts, in order to evaluate whether as an effective self-care practice for them This Dissertation is available in Open Access at AURA: Antioch University Repository and Archive, http://aura.antioch.edu and OhioLink ETD Center, http://www.ohiolink.edu/etd ŝǀ Table of Contents Abstract iv Chapter I: Introduction Chapter II: Literature Review Benefits of physical exercise 12 Mindfulness 16 Overview of martial arts 20 Review of the Literature on the effects of martial arts pUDFWLFH««««««««««« Martial arts practiced by the pDUWLFLSDQWV«««««««««««««««««««« Karate 25 Kung Fu 26 Brazilian Jiu Jitsu 28 Aikido 29 Muay Thai 29 Chapter III: Research Methods 32 Subject selection 32 Inclusion and exclusion criteria 33 Methods 34 Internal and external validity 35 Participant profiles 36 Methodology 37 Chapter IV: Results 39 Themes 39 Occupational stress 39 Martial Arts as a self-care practice«««««««««««««««««««««« Challenges of martial arts training 49 Martial arts and clinical practice 52 Chapter V: Discussion 56 Limitations 59 Implications for future research 60 Conclusions 60 ǀ References 62 Appendix A: Informed Consent 68 Appendix B: Interview Protocol 69 ǀŝ Chapter I: Introduction Mental health professionals face a vast array of demands in the workplace Not only must they manage the typical responsibilities of employment including organization of tasks, effective communication, and maintaining current training certifications, they are also required to manage the emotional burdens that are inevitable in their respective field For the purposes of this dissertation,ƚheODEHO³mental health professional´ represents Clinical Psychologists, Licensed Marriage and Family Therapists, Licensed Clinical Social Workers͕ and Psychology-interns and practicum trainees (Psy.D.) who provide therapeutic services For these individuals, the stressful and often traumatic cases they see not simply vanish once they clock out Given the nature of their work, mental health professionals are vulnerable to stressors that challenge them emotionally, physically, spiritually, and can impact their cognitive resources and psychological well-being (Portnoy, 2011) When conscious efforts are not made to manage work-related stress for mental health practitioners, research has found that such practitioners are highly vulnerable to experiencing distress that has a negative impact on their daily functioning The term commonly used to describe the negative impact of work-UHODWHGVWUHVVLVàRFFXSDWLRQDOEXUQRXWả7KLVWHUP encompasses a wide variety of symptoms that can potentially cause significant distress Occupational burnout can lead to depression, anxiety, compassion fatigue, distraction and decreased self-awareness, and the risk of such consequences may increase with a lack of socialsupport (Carter, 2013) Over the course of their career, many mental health professionals will be tasked with treating individuals who present a wide variety of traumatic experiences Mental health ϭ  professionals who face such challenging cases are at risk of experiencing some level of secondary trauma as a result Secondary trauma is a term that describes the emotional distress experienced by an individual who hears about the firsthand traumatic experience of another person (Baum, 2016) The symptoms of secondary trauma mimic the symptoms of posttraumatic stress disorder (PTSD) It is commonly accepted that mental health professionals can expect to experience a significant amount of emotional activation given the often painful and distressing material their clients share with, and sometime direct toward them Psychotherapists are often exposed to stories of trauma, complex and highly negatively charged interpersonal interactions, tragic stories, and complicated ethical issues and mandated reporting questions A psychotherapist must absorb much painful affect and still be able to approach delicate issues with equanimity and competence if they are able to develop and implement treatment plans to target maladaptive behaviors and reduce the severity of the clientV¶VXIIHULQJ Much research indicates that to provide effective psychotherapy, mental health professionals should engage in effective self-care practices to alleviate the occupational stress that they experience (Portnoy, 2011; Figley, 2002) Under Principal II: Responsible Caring of the Canadian Code of Ethics of Psychotherapy; 3ULQFLSDO,,VWDWHVWKDWSV\FKRORJLVWV³(QJDJHLQVHOI-care activities that help to avoid conditions that could result in impaired judgment and interfere with their ability to benefit and QRWKDUPRWKHUV´3RSH 9DVTXH] TKH$PHULFDQ3V\FKRORJLFDO$VVRFLDWLRQ¶V*HQHUDO 3ULQFLSOHV3ULQFLSDO$%HQHILFHQFHDQG1RQPDOHILFHQFHVWDWHVWKDW³3V\FKRORJLVWVVWULYHWREH aware of the possible effect of their own physical and mental health on their ability to help those ZLWKZKRPWKH\ZRUN´3RSH 9DVTXH] 7KHVH statements reflect the mental health SURIHVVLRQDOV¶HWKLFDOGXW\WRDFWLYHO\HQJDJHLQDFWLYLWLHVWKDWPD\UHGXFHWKHULVNRI Ϯ  ones who are too aggressive in training These circumstances not only increase the risk of injury, but they also crate tension among peers thus reducing the positive experience of training Participant explained that injuries were common for him during some of his Kung Fu training, especially during sparring He described a heated sparring session where emotions were running high Participant described feelings of frustration and aggression and eventually he injured his partner, rendering his peer unconscious Participant explained that he felt terrible following this incident Fortunately, the Sifu (instructor) was aware of the tension during this sparring session Following this incident the Sifu adjusted 3DUWLFLSDQW¶VWUDLQLQJ, implementing more mindful techniques such as Tai Chi and soft movements to promote emotional regulation Participant also explained that LQMXULHVDUHFRPPRQLQPDQ\³KDUG´VW\OHVRI.XQJ)XDQG Karate As an experienced martial artist in hard styles of martial arts, Participant noted that coping with frequent injuries can compound occupational stress and negativel\LPSDFWRQH¶V work experience In summary, Participants and described similar experiences with interpersonal tension in sparring It is commonly accepted among martial artists that sparring is a partnership where people help each other improve, and refrain from intentionally injuring each other (Fightscope, 2010) There are times however, when students treat sparring more as a competition and less as a learning partnership Under strained circumstances, participants and agreed that it is important to stay humble and not take matters personally, especially when one is bested by another in sparring In regards to personal injury, both participants shared experiences of coping with chronic mild-PRGHUDWHSDLQ7KLVLQIRUPDWLRQVXJJHVWVWKDWRQH¶VSUHIHUUHGPDUWLDODUWFDQ present both challenges and benefits, and one may want to weigh these two elements during their martial pursuits ϱϬ  Participants 4, and reflected on present awareness in training Participant noted that it can be challenging to be truly present during training She explained that it is important to listen with the body, EHFDXVHH[FHVVLYHFRJQLWLYHDFWLYLW\FDQUHGXFHRQH¶VVRPDWLFDZDUHQHVV during training She also mentioned the importance of being aware of physical limitations when WUDLQLQJ³7KHUHare so many limitations of the body,´6KHVDLG ³I am now 65 and so some days WKHFKDOOHQJHZLOOEHàFDQ,PRYHDVTXLFNO\DVVRPHRQHZKRLVWKLUW\DQGZHOOWUDLQHG"ảor does LWPDWWHU"2UFDQ,VKRZXSDQGEHSUHVHQWIRUZKDWảVJRLQJRQ"7KLVVWDWHPHQWUHIOHFWVWKH challenge of training at an age when one must be mindful of differences in physical ability and WKDWRQHPXVWXQGHUVWDQGRQH¶s own limitations to avoid injury Participant said that sometimes she gets ³ORVWLQP\KHDG´UHJDUGLng her job She presents as a hard working professional who often thinks about her caseload, even when she is not at work She explained that it can be difficult to set aside occupational considerations and maintain focus on training Participant stated that ³%HLQJPLndful of my own presenFH´FDQEHDFKDOOHQJHDWWLPHV He emphasized the importance of body-mind presence in training Aikido emphasizes that the body expresses what the mind desires Participant described that at times he can be too tense and unable to flow fluidly with his training partners +HDOVRQRWHGWKH³=RQHRISUR[LPDO GHYHORSPHQW´ZKLFKLVWKH difference between what a learner can independently versus what he or she can with assistance For him, Participant noted that it is helpful when the instructor points out when he is too tense in order to help ground the participant in the present moment of training Reflecting the importance of a balanced presence of body and mind is a common theme among participants ϱϭ  Martial arts and clinical practice Another theme that emerged during the interviews was the connection the participants made between martial arts training and their ability to provide therapeutic services All eight participants reported that martial arts training is beneficial to their functioning at work Participant said that BJJ helps to regulate his mood He explained that he is prone to symptoms of anxiety and depression, and that the physical aspect of training helps reduce these symptoms Participant also shared that training in BJJ has helped him be more present, and to provide structure and continuity for his clients Lastly, he noted that martial arts provides him with the confidence that if a client became hostile, he feels equipped to handle such a situation without causing injury to the client Participant reported two notable benefits of training in Kung Fu as a mental health professional He explained that Kung Fu ³made me less afraid of you know, big strong violent, psychotic patients´ He added: ³I think in general with psychotherapy, my experience with martial arts allowed me to be more calm.´ Participants and frequently attributed increased confidence as a psychotherapist to their training in martial arts Participant explained how he felt Karate helped him in his development as a psychotherapist During the interview he said: ³I think karate has trained my mind, not just my body, in really thinking things in a different way, and it helps me with my clients.´ Participant also shared that co-workers can be a stressor for him in his work He said: ϱϮ  ³,play ok with others but um you always find someone that rubs you the wrong way so it helps me to manage that.´ Participant reflected on the mind body unification that is emphasized in Aikido She explained: ³6ome kinds of Aikido are physically and psychologically healing, and I bring that into the therapeutic container The being centered in Aikido is the same as being present in psychotherapy.´ Participant continued to share that the unique training methods of Aikido promotes interpersonal attunement, or a greater sense of harmony and connection between individuals Participant considered her training in Muay Thai as beneficial to her overall occupational experience She said: ³It helps DQG,DOVRXVHWKHVWUDWHJLHVDQGWHFKQLTXHVWKDW,¶PWDXJKW, and I can teach that to adolescent boys with anger issues I think martial arts are great with that.´ Participant elaborated on how Muay Thai training has helped increase her focus and attention, helping her become a better listener and providing her with additional coping skills to teach her clients Participant explained that Aikido goes side by side with the field of psychology, and that her Aikido training has significantly influenced her therapeutic approach She said Aikido has given her greater spatial awareness, patience, and resiliency in the face of challenging issues as a psychotherapist In regards to her therapeutic approach, she said: ϱϯ  ³)RUPHLW¶VDTXLFNHUUHIHUHQFe point to use my Aikido in therapy then to go to what I learned in grad school To be perfectly honest Aikido is a lot more present in my work For instance, just that physical awareness and spatial awareness you can read people in a ZD\WKDW\RXFDQ¶WJHWWUDLQHGLQSV\FKRORJ\DQGWKHUH¶VDZD\WKDW\RXFDQUHDGLID situation is going to present certain issues.´ Participant said that Aikido ³allows me to stay regulated and to be present with that energy without needing to shrink away from it, silence it, or control it.´ This statement reflects WKHLPSRUWDQFHRIKROGLQJRQH¶VFRPSRVXUHDVDSV\FKRWKHUDSLVWGXULQJVHVVLRQDQGWKDWWUDLQLQJ Aikido can provide psychotherapists with greater levels of emotional regulation, spatial awareness, and acceptance of tension that may arise in session Participant stated that the benefits of Aikido have generalized to his occupational field However, he suggests that there are many self-care activities that could potentially offer similar results, and it depends on the best fit for the individual He explained: ³$LNLGRILWVLQP\ZRUOGEHFDXVHLW¶VDOODERXWPDNLQJFRQQHFWLRQV,WKLQN,EHFDPH better at making connections with supervisees and my patients, as a result in practicing Aikido On the other hand, had I just meditated every day, maybe the same thing would have happened? Had I just taken yoga every day, maybe the same thing would have happened.´ The study presented valuable information in regards to martial arts as a self-care practice The data sets suggest that martial arts training offers physical, emotional and cognitive benefits For example, Participant noted that training in Karate helped increase his energy level at work, and increased his tolerance of co-workers who can be difficult to work with Participant ϱϰ  reflected on the physical benefits, and shared that Muay Thai KHOSHGKHU³JHWRXWRIP\PLQGDQG LQWRP\ERG\´The data suggests that martial arts can relieve stress through mindfulness practices Clinicians who train Aikido presented the most significant data on mindfulness practices and martial arts All four Aikido participants indicated that their preferred martial art increases emotional regulation, and can be a useful tool in connecting with their clients during therapy Overall, the value of martial arts as a self-care practice depends on the suitability of the style for the individual Not all martial arts styles can be generalized as an effective self-care tool for mental health professionals Participant provided valuable insight when he said ³7heUH¶V many ways up the mountain I think yoga, running, Aikido, all these things could get you to the VDPHSODFH)RUPHLWZDV$LNLGR´ ϱϱ  Chapter V: Discussion The purpose of this study was to evaluate martial arts as a self-care practice for mental health professionals The discussion section examines the identified themes and considers these findings with the research presented in the literature review The discussion section also discusses limitations of this study and implications for future research A significant portion of the data in the results section corroborates with data in the literature review The literature review includes research on occupational stress and burnout, the effects of mindfulness activities, physical fitness, and effects of martial arts training The literature review examines both quantitative and qualitative research studies Literature on martial arts includes a variety of styles including Judo, Aikido and various forms of Karate and Kung Fu This dissertation explores the subjective experience of participants from a broad range of professional backgrounds including Masters level psychotherapists, Clinical Psychologists, Psychological Practicum Trainees and Interns These participants provide services in diverse environments from private practice to psychiatric hospitals The participants also present a diversity of martial arts backgrounds including Aikido, Brazilian Jiu Jitsu, Cajun Ryu Karate, Wing Chun Kung Fu, Tai Chi, and Muay Thai Four of the eight subjects practiced Aikido as their preferred martial art These four participants included one male Clinical Psychologist, one male LMFT, and two female LMFTs, all from different geographic locations including California, Washington DC and Washington State When these four participants were asked why they chose this style, all four participants had similar responses The Aikido participants noted that their chosen style is unique because it ϱϲ  promotes non-violence and harmony Two participants even responded that the art is very much like providing psychotherapy in that one is tasked with meeting resistance with harmony, and approaching tension with a gentle, flowing approach that promotes a connection between the two individuals rather than collision Researchers Lothes, Hakan, & Kassab (2013) demonstrate that Aikido adopts a mindfulness-based approach to martial arts Their study compared Aikido students of varying levels of experience with a control group for mindfulness skills and concentration Lothes, Hakan, & Kassab used the Kentucky Inventory of Mindfulness Skills (KIMS) and the Mindfulness Attention Awareness Scale (MAAS) The results concluded that Aikido students of all levels scored higher on the KIMS and MAAS tests than the control group.These results corroborate the greater levels of spatial awareness, and awareness of personal emotions and reactions during therapy that were reported by many of the Aikido participants The literature review includes studies that explore the effects of mindfulness practices on occupational experience2QHTXDOLWDWLYHVWXG\H[SORUHGPHQWDOKHDOWKSURIHVVLRQDOV¶H[SHULHQFH with mindfulness meditation and empathy towards clients (Aiken, 2006).Participants RI$LNHQ¶V study attributed regular mindful based meditationƚŽincreased awareness and empathy for their clients 7KHGDWDIURPWKLVGLVVHUWDWLRQ¶VAikido participants corroborates Aiken¶V data, supporting mindfulness practices as a tool to promote empathy for clients Participant practices Cajun Ryu Karate for self-care He attributed his Karate training to greater self-confidence, strength, stamina and frustration tolerance 7KLVSDUWLFLSDQW¶VUHVSRQVHV DUHVLPLODUWR%RXGUHDXDQG.R]QDN¶VUHVHDUFKthat demonstrates an association between Karate training, increased relaxation and self-efficacy (1984) ϱϳ  Participant practices Muay Thai During her interview, she shared that Muay Thai is physically demanding and the intense workouts help reduce occupational stress She explained that she often feels better physically and mentally after a Muay Thai session The literature review discusses a meta-analysis that examined the relationships between physical activity and overall health (Dahn & Penedo, 2005) The researchers found beneficial, positive effects across several mental health and physical outcomes including improved mood and reduced symptoms of depression and anxiety Question 15 RQWKHSURWRFRODVNV³How would you describe your experience working with your clasVPDWHVLQWKHGRMR"´Participant reported significant positive interpersonal experiences at her Aikido school She said: ³,¶YHJRWRQHIULHQGZKR,¶YHWHVWHGHYHU\VLQJOHOHYHOKH¶VOLNHP\$LNLGREURWKHU