Wellness for Care Providers: Surviving the Cycle of Caring

Caring professions, also called helping professions, are those where the role means directly caring for others physically, mentally, or emotionally. Some of the most common caring professions include nurses, teachers, social workers, and mental health therapists. 

When you work in a caring profession, there can sometimes be a disconnect between how you care for others and how you care for yourself. It’s easy to give too much and not refuel yourself when you need it, which can quickly lead to burnout.

To ensure a healthy balance and care for both yourself and others, it’s important to understand the cycle of caring and create a plan for managing your self-care. In this blog, we’ll explain the four stages of the cycle of caring and show you how to begin assessing the stressfulness of your job so you can best take care of yourself. 

Ciera Jackson, our Professional Development Specialist here at Cummins, shares her expert advice about the cycle of caring and creating a solid self-care plan for your own personal wellness.

Ciera Jackson, MSW, LCSW, Professional Development Specialist at Cummins Behavioral Health

Explaining the Cycle of Caring

The cycle of caring is the process that happens when professionals, such as therapists, provide help to clients without receiving help in return. 

This process happens continuously in the helping professions because clients come and go. The therapist helps the client, the client puts the lessons into action, and then the therapist has to let go of that relationship because they’re no longer needed.

There are four stages of the caring cycle: empathetic attachment, active involvement, felt separation, and re-creation.

Empathetic Attachment

The first stage of the cycle is all about building rapport. During empathetic attachment, the practitioner must be open to what a client needs and be emotionally compassionate. Ciera explains, “This is the phase where you’re building rapport with a client, the client is emotionally vulnerable with you, and where you’re other-oriented.”

The empathetic attachment phase requires you, as someone serving another person, to be “on” and lend yourself to other people. It’s all about connection and trust.

Active Involvement

After empathetic attachment, the next stage is active involvement, which is where the professional invests time and energy to use their skills in helping the client. This is the phase most caring professionals spend the most time in. 

It’s the phase where professionals must figure out what the client needs, whether that’s assistance with anxiety, depression, social skills, or relationships. Ciera notes, “You have to reach for all these different tools in your tool bag.” 

Active involvement is also about making coping tools accessible to people who may not understand them or be overwhelmed by where to start. “It’s our job to help them simplify it. That’s what we have to do in the active involvement phase. We have to simplify things for them so it’s not so overwhelming,” Ciera says.

Felt Separation

During felt separation, the professional’s work is complete. The client applies what they’ve learned, and the practitioner detaches themself from the relationship. No matter what kind of role a professional fills, there are bonds created with the people they regularly serve, which means almost everyone in a caring field feels separation at some point. 

This separation isn’t always easy. Ciera says, “Sometimes it’s very uncomfortable, and sometimes it’s bittersweet because you have an attachment to them. It can be a great attachment, but you are not in their life permanently, and that’s a good thing. That’s a great thing.”


As the caring cycle ends for one relationship and the separation is finalized, a caring professional should take time for re-creation. “Get some rest. Get away from work, hit the ‘off’ button. That’s what should happen in this cycle,” Ciera emphasizes. 

For many people, this can be a challenge because of the pressure to be constantly productive and on the go. Ciera tries to remind herself and her co-workers, “I need to shut it off. I need to shut it down. I need to prioritize myself, because you can’t pour from an empty cup. You can’t give what you don’t have and you can’t run on fumes.”

Ciera adds, “Sometimes people don’t give themselves permission to take the time to rest, because even when they’re resting, they feel like they should be doing something and making themselves busy. When you don’t rest, your body starts to give warning signs that say ‘Attention, I need you to stop.’ ”

Care and the Practitioner

Generally speaking, we know what happens for the client during these phases, but what’s happening for the practitioner? How are they responding and coping with the stresses and different stages of the caring cycle? 

Caring is a precondition for an effective helping relationship.

Ciera puts it plainly: “If you’re going to be effective in your work, you have to care.” For caring professionals, caring is quite literally part of the job, and that feeling must exist for them to do well and care for others in an effective way.  

Inability to care is the most dangerous signal of burnout, ineffectiveness, and incompetence. 

If you find yourself in a situation where you don’t or can’t muster a feeling of caring, “that likely means you’re burnt out, which means you’ll be ineffective and incompetent,” Ciera says.

Low points and burnout occur for everyone, regardless of what your role may be. However, as a caring professional, it’s essential to rejuvenate before you find yourself unable to care. Ciera encourages, “If you feel in your spirit that you don’t care, take a little break. Take a little leave of absence because that’s not how you should feel.”

She also points out that you should try to avoid reaching a point where your work and character are deemed questionable, or where people wonder whether you’re competent, because these doubts can follow you into the future.

Sustaining oneself, being vital, and being active in the caring professions means being fully present for the Other.

When you’re providing care to others, it’s important to be present and in the moment. “We to be fully present for the people we are working with,” notes Ciera. The clients are counting on you, and it’s your job to ensure you have the capacity to provide the care they need. That starts by taking care of yourself. 

Repeatedly, a practitioner must engage in a mini-cycle of closeness with the consumer and  grief over the end of the professional relationship.

“This is what we do. We get close and then we have to let go,” Ciera says. The cycle can be difficult for practitioners because some relationships and bonds are very strong. While this is great for facilitating helping, it can also make it more difficult to let the relationship end.

The Self-Care Action Plan

As a caring professional, you need to make sure to leave enough time for self-care. A Self-Care Action Plan can be an invaluable tool toward this end. At Cummins, we use a Self-Care Action Plan template inspired by the book The Resilient Practitioner: Burnout Prevention and Self-Care Strategies for Counselors, Therapists, Teachers, and Health Professionals by Thomas Skovholt and Michelle Trotter-Mathison.

In the remainder of this post, we’ll go over the first two steps of creating your Self-Care Action Plan: assessing your work stress and determining what kind of self-care/other-care balance you have in your life right now.

Step #1: Assess the Stress Level of Your Work

Work stress can be determined by assessing three factors: Demand, Control, and Social Support.

First, consider the following questions to assess the Demand of your work:

  • Do I have to work very hard for my job?
  • Am I asked to do an excessive amount of work?
  • Do I have enough time to get my work done?

Based on your answers to these questions, give yourself a rating from 1–5 for how demanding your work is, with 1 being low demand, 3 being moderate demand, and 5 being high demand.

Next, assess the Control you have in your work by considering:

  • Do I have to do a lot of repetitive work?
  • Do I have much freedom to decide how my work gets done?
  • Do I get to be creative in my work?
  • Do I get to learn new things for my work?

Use your answers to give yourself a rating on how much control you have over your work. Again, let a score of 1 indicate low control and a score of 5 indicate high control.

Finally, assess your level of Social Support by asking yourself:

  • Do I work with helpful people?
  • Do my co-workers take personal interest in me?
  • Is my supervisor helpful?
  • Is my supervisor concerned about my personal welfare?

As you did for Demand and Control, give yourself a rating from 1–5 indicating how much social support you receive in your work.

Once you’ve determined all three scores, you’ll have a better picture of exactly how stressful your work is. High demand, low control, and low support all tend to increase job stress. By contrast, the least stressful jobs combine high control and high social support with low demand.

Step #2: Give Yourself a Balance Score

Once you’ve determined how stressful your job is, consider how much you care for others versus yourself. Ask yourself: Do I tend to give more other-care and less self-care? Or do I tend to give more self-care and less other-care? Or am I about even?

Determine your current ratio of self-care to other-care. For example, if you are perfectly balanced, your score would be 50/50. If you are highly imbalanced, your score might be 90/10 (90% self-care to 10% other-care) or 10/90 (10% self-care to 90% other-care).

Once you’ve determined your balance, think carefully about any imbalances you see. If you find that you have a very unbalanced score, consider: What are some of my imbalances? Why am I out of balance?

These questions can be informative and enlightening  when it comes time to determine the wellness practices that will help you correct any self-care/other-care imbalances.

For caring professionals, caring about other people is part of the job description. This can result in work that is personally rewarding and deeply fulfilling. It can also create situations that are highly stressful and emotionally exhausting.

Fortunately, having a Self-Care Action Plan can help caring professionals balance the demands and responsibilities of their work. In future articles in our series on Wellness for Care Providers, we’ll explain how you can improve your self-care practices, focusing on areas like professional care, personal care, and physical care. Stay tuned!

Introducing TMS: A New Service Option for Treatment-Resistant Depression and OCD

Approximately 19.4 million adults in the U.S. have been diagnosed with major depressive disorder, also known as major depression. An additional 2–3 million adults live with obsessive-compulsive disorder. Together, that’s 9% of the total adult population whose daily lives are affected by these common disorders.

Many of these individuals can find relief from their symptoms with the use of psychotherapy, medication, or a combination of both. With a little help from medical professionals, most people can learn to manage their disorders and live full, enriching lives in spite of their mental health challenges.

However, about 33% of people with major depression and 40–50% of people with OCD do not see improvement in their condition even after undergoing the normal treatments. In these cases, their disorder is known as “treatment resistant.” Treatment-resistant disorders can severely impact a person’s daily functioning and destroy any hope that their condition will ever improve.

Finding new ways to manage treatment-resistant disorders is an ongoing challenge in the mental health field, but breakthroughs do happen. One notable development is transcranial magnetic stimulation, or TMS, which has been found effective at helping individuals with treatment-resistant depression and OCD. Although results vary from person to person, research has shown that 73% of participants with depression and 58% of participants with OCD see a noticeable reduction in their symptoms after a full course of TMS treatment.

Cummins has recently received a Federal grant that will allow us to provide TMS treatment for our consumers at our Avon office. We’re very excited for this opportunity to better serve our community, and we want to answer any questions you might have about this new treatment!

In this blog post, Cummins’ Medical Director Dr. Steven Fekete explains who will be eligible for this treatment, how it is different from other forms of treatment, and what you could expect if you were to begin a course of TMS treatment at Cummins.

Steven Fekete, M.D., Medical Director at Cummins Behavioral Health

What Is TMS?

Transcranial magnetic stimulation is a form of treatment that uses electrical impulses and magnetic fields to affect the functioning of the brain. These impulses are created by a series of powerful magnets, which are placed around the patient’s head and controlled by a special machine.

Dr. Fekete explains, “The machine creates these little magnetic fields over different parts of the brain, and those magnetic fields then induce the brain cells to depolarize or become active, therefore regulating brain activity and helping that individual address the symptoms that they’re experiencing from their disorder.”

The electrical impulses are administered in waves over a period of several minutes, so this treatment is technically called repetitive transcranial magnetic stimulation (rTMS). The latest equipment is also capable of sending these impulses deeper into the brain than earlier machines could, which makes this specific form of rTMS deep repetitive transcranial magnetic stimulation (drTMS).

As we said above, drTMS is targeted toward individuals who suffer from treatment-resistant depression or OCD. “Treatment resistant means a person has used at least two antidepressants at maximally tolerated doses for six weeks, and received a course of evidence-based therapy, and they just did not get the response that they had hoped to,” Dr. Fekete explains. “Unfortunately, in the psychiatric field, the response rates of antidepressants are not where we’d like them to be. So there are a lot of individuals who experience this.”

At Cummins, we are especially interested in making drTMS available for individuals who get their health insurance through Medicaid, as this population has had poor access to TMS treatment in the past. “Treatment for depression is reimbursable through Medicaid, but there are a lot of individuals who we specifically want to target because Medicaid doesn’t pay for it. For example, we’re using the grant to help pay for individuals with OCD,” Dr. Fekete says.

How TMS Treatment Works

As we’ve mentioned, drTMS works entirely through the use of electromagnetism.

“An individual comes into the office, and they sit in a chair under this thing that kind of looks like an old hair dryer,” Dr. Fekete explains. “And they wear a cushioned helmet underneath this more rigid helmet.”

When the machine is turned on, the exterior helmet passes electric currents through a series of electromagnetic coils. The person wearing the apparatus can hear this as a repeated tapping or clicking sound. The coils inside the helmet create an electromagnetic field that reaches about 1 to 2 inches into the wearer’s brain, which stimulates neural activity in specific areas of their brain. For example, for patients suffering from depression, the apparatus is configured to stimulate the dorsolateral prefrontal cortex.

The magnetic field is similar in intensity to an MRI scan, and it is safe for the majority of people. However, side effects of drTMS treatment can include headaches, pain or discomfort at the treatment site, and jaw pain. No individual who has metal on or inside their head (which may include plates, medial devices, shrapnel, or metallic tattoos) is eligible for drTMS treatment, as the magnetic fields can be dangerous for these persons. Other possible contraindications include suicidal ideation, psychosis, substance use, and pregnancy or lactation.

Other pros and cons of drTMS include:


  • The treatment is non-invasive and is performed in an outpatient setting
  • Most patients can drive themselves to and from their appointments
  • No memory loss or cognitive impairments
  • Any medications may be continued during treatment


  • Risk of minor side effects (headaches, site pain, jaw pain, muscle twitches)
  • Very low risk of seizure, mania activation, and hearing loss
  • Large time commitment (20-minute sessions for 30–36 days over a span of 6–12 weeks)

Dr. Fekete sums up the pros and cons of drTMS: “To me, the biggest advantage is you can drive to the appointment and drive away. The biggest downside is it’s very time consuming. I think about people who work, or who have responsibilities for children, or maybe responsibilities for an older adult or somebody else in their life. That may be very difficult to get around. They may have to arrange for somebody to take care of things at home while they’re gone. But once they’re done, they’re not impaired from the treatment to do whatever they need to the rest of the day.”

Example of what the drTMS machine looks like when in use

A Typical TMS Treatment Session at Cummins

If you or a loved one are eligible for drTMS treatment and choose to receive it through Cummins, it begins with a conversation with our Central Access Office.

Dr. Fekete explains, “An individual would reach out to our Central Access saying they’re interested in getting TMS. We would also take a referral from a provider who might call us and say, ‘I have such and such, would they be eligible for getting TMS?’ “

Depending on the person’s eligibility and insurance coverage, the next step would be an initial consultation about drTMS services. “We would set up an appointment for that individual where we would come in and interview them,” Dr. Fekete says. “This psychiatric evaluation takes about an hour. We would go over the process with them and then determine if they are still interested in in it after reviewing the risks and benefits, side effects, etc. We would also take them over and show them the treatment room as long as there wasn’t anyone in there.”

Next would come the first drTMS appointment, which involves taking neurological measurements of the patient’s brain. “We map their activity in their motor cortex, and a percentage of that is utilized to adjust the magnetic impulses that will be used in their treatment,” Dr. Fekete explains. “It takes about an hour. Either myself or the other physician would be there the majority of the time, because we’re doing that mapping with the assistance of a technician.”

After this mapping session, the patient can begin attending treatment sessions based on the schedule determined with their provider. “It’s usually 30 treatments that are 20 minutes each,” Dr. Fekete says. “After the first appointment, you would not necessarily interface with the prescriber, you would interface with the person who is going to be setting up the machine. You would come in for your 20 minutes, and then you would leave. And that’s it.”

As you progressed through treatment, you would also continue your normal therapy or psychiatry appointments, if you were receiving these services. Dr. Fekete explains, “The TMS is freestanding, yet part of a larger approach to managing some of these more significant treatment-resistant illnesses that we face. The nice thing is that the TMS is one item in an armamentarium we can use to help people manage their illness. So it fits in with medication, it fits in with therapy, skills training, self-help groups, mutual help groups, and meditation.”

According to Dr. Fekete, the most important aspect of drTMS treatment at Cummins is that we are able to bring a new standard of care to people who did not previously have access to it. He says, “I only know of one other place in Indiana that currently provides TMS for the Medicaid-based population. This has been around for 13 years, it’s FDA approved, it’s Medicaid payable, but it’s not being offering to these people. This gives people access to care that they should have had since 2008.”

If you are interested in exploring the possibility of drTMS treatment for yourself or someone under your care, we encourage you to speak with your psychiatrist, therapist, or care provider. If you would like, you can also call us at (888) 714-1927 to speak with someone about drTMS services.

Suffering from a treatment-resistant mental illness can be extraordinarily difficult and discouraging, but with the help of new treatment technologies like drTMS, recovery is possible!