Caring About Care: The Paradox of Self-Care in Occupational Therapy

Self-Care as a Growing Concern in Occupational Therapy

Self-care has become an increasingly visible concern in occupational therapy (Jeffords, 2026; Laposha & Smallfield, 2022; Popova et al., 2022; Richardson, 2026; Zeman & Harvison, 2017). This is unsurprising, considering that occupational therapy practitioners work in demanding contexts shaped by complex client needs, emotional labor, productivity expectations, documentation requirements, workforce shortages, and increasing pressures on healthcare systems. Against this background, burnout, stress, compassion fatigue, and professional exhaustion have become recurring concerns in occupational therapy practice, education, and workforce sustainability (Popova et al., 2022; Shin et al., 2022).

The occupational therapy literature has positioned self-care as a plausible response to these concerns (Jeffords, 2026; Laposha & Smallfield, 2022; Popova et al., 2022; Richardson, 2026; Zeman & Harvison, 2017). If practitioners are expected to support the health, wellbeing, participation, and everyday functioning of others, then their own capacity to remain healthy, engaged, and occupationally balanced becomes professionally relevant (Richardson, 2026). Calls for self-care protocols in occupational therapy therefore make intuitive sense: those who care for others must also sustain their own capacity to care (Zeman & Harvison, 2017).

Yet through a caring perspective, this very plausibility requires closer examination. When professional exhaustion is addressed through self-care, exhaustion becomes visible in a particular way: as a problem of insufficient care for the self. This framing may support practitioners, but it may also shift attention away from organizational, institutional, and systemic conditions such as workload, staffing, productivity standards, supervision, professional recognition, and emotional demands. Self-care can therefore become both a necessary resource and a narrowing lens.

Against this background and drawing on a form-theoretical lens (Luhmann, 1999; Spencer-Brown, 1979; Staller & Koerner, 2026b), we theoretically examine self-care more closely. By doing so, we argue that self-care is a paradoxical extension of the care imperative (the second section). By analyzing the form of self-care (the third section) we arrive at a paradox-oriented understanding of self-care practice (the fourth section) that opens up a broader range of possibilities for caring for ourselves (the fifth section).

The Paradox of Self-Care

Self-care is a widely used concept in occupational therapy (Laposha & Smallfield, 2020), which is embedded within the operational logic of occupational therapy. The profession understands occupations, including activities of daily living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation as central to health and participation (American Occupational Therapy Association, 2020). Within this context self-care can therefore be understood as an occupation-based concern, even in the absence of an agreed-upon definition of the term (Laposha & Smallfield, 2020). Depending on its definition, self-care may involve how people organize rest, work, boundaries, relationships, recovery, and meaning in ways that support their continued participation in professional and personal life and as such promote health and wellbeing.

At the same time, the vocabulary of self-care does not apply only to clients. It also provides occupational therapy with a semantic frame through which the profession can address the practitioner as an occupational being. The therapist is not only observed as a provider of care, but also as someone whose own routines, resources, boundaries, and occupations matter. In this sense, self-care emerges from within the profession's own conceptual vocabulary: Care is reflexively extended to the self of the carer.

In a broader sense, the promise of self-care is to promote health, wellbeing and the relief from strain (Laposha & Smallfield, 2020). It offers practitioners ways to recover, regulate, set boundaries, and sustain their professional capacity. In this sense, self-care responds to a problem made visible in occupational therapy: care work can exhaust those who provide it (Park, 2021; Porter & Lexén, 2022; Torp & Bergheim, 2023; Turner et al., 2024; Yan et al., 2024). Yet self-care also changes the structure of expectation. The practitioner is no longer only expected to care for clients, but also to care for the self that cares. It addresses the burden of care by asking practitioners to care for their own capacity to care. In doing so, self-care may relieve care while also adding another care demand.

We observe this paradoxical extension of the care imperative as the paradox of self-care. Self-care addresses exhaustion through the same logic that contributes to exhaustion: the expansion of care. ¹ This paradox becomes particularly visible in the relation between organizational conditions and individual responsibility. Burnout in occupational therapy has been associated with workplace and professional factors, including workload, time demands, resources, autonomy, income satisfaction, supervisor support, professional identity, role conflict, and recognition of the profession (Shin et al., 2022). Yet the proposed response is often directed toward the individual practitioner: rest, resilience, mindfulness, occupational balance, boundary setting, or other self-care practices.

In this way, self-care can become a problem-generating solution. It responds to a problem that is, at least in part, organizationally and systemically produced, but translates the practical response into individual care work. The problem from this perspective is that practitioners may be expected to manage the effects of being overburdened (which has been the origin problem of self-care). Self-care may acknowledge structural conditions, yet still leave the practitioner responsible for adapting to them.

Critical self-care literature describes this ambivalence: self-care can support survival, recovery, and resistance, but it can also reproduce neoliberal expectations of self-responsibility, optimization, and individual adaptation to structural strain (Martínez-Jiménez, 2023; Salmenniemi, 2026; Welsh, 2020). It may help practitioners cope with stress, while simultaneously making stress communicatively available as a recurring condition of professional life. In other words, self-care does not simply respond to stress; it may also contribute to the stabilization of stress as an expected background of occupational therapy work. This shows its practical ambivalence. Self-care can protect practitioners, but it can also intensify the responsibility placed on them. It can open possibilities for recovery, but it can also reproduce the conditions under which recovery becomes necessary. Self-care, as a form, carries the problem it seeks to address.

The Form of Self-Care

From a practical perspective, the paradoxical nature of self-care may initially appear as a problem. Professional practice is often oriented toward coherence: Problems are identified, logical paradoxes are to be reduced, and solutions are expected to resolve the tensions from which they emerged (Luhmann, 1995a). A form theory of observation suggests a different analytic orientation (Staller & Koerner, 2026b). Paradoxes may not only be treated as obstacles to coherent practice, but as structural features of observation (Luhmann, 2005), that might prove fruitful.

To clarify our theoretical argument, we first provide a brief introduction to the form- and systems-theoretical perspective used in this article. Form theory and systems theory cut across disciplinarily organized bodies of knowledge because they do not begin by accepting disciplinary perspectives as neutral descriptions of reality. Rather, they treat these perspectives themselves as forms of observation and ask what they make visible, what they leave unobserved, and which blind spots they reproduce. Form theory reconstructs how something can become observable as something (Luhmann, 1995b, 1999). It therefore provides a foundational tool for analyzing any body of knowledge, including empirical, professional, and clinical forms of knowledge. Systems theory, in the sense developed by Niklas Luhmann (Luhmann, 1996), builds on this insight by analyzing how social systems—such as science, politics, law, healthcare, or organizations—distinguish themselves from their environments and reproduce themselves through their own communicative operations. Put more practically, systems theory examines how systems stabilize their own logic and how this logic determines what can appear as relevant information. This theoretical lens also makes it possible to reconstruct how systems know what they know. For example, through this lens empirical research does not simply mirror an external reality. It contributes to stabilizing a specific horizon of visibility by defining what counts as data, evidence, method, object, and result. In this sense, form and systems theory offer a way to open new possibilities for professional observation by making visible the distinctions through which a profession observes its own problems and solutions (Staller & Koerner, 2026a).

The form-theoretical argument begins with the assumption that observation is the gateway to world. Without observation, nothing can be known. Every observation is an indication within a distinction. From the perspective of form theory, something does not appear as simply given. It appears as the marked side of a form whose other side remains unmarked (Spencer-Brown, 1979). What appears as “the phenomenon” owes its visibility to the difference against which it is marked. From this perspective, the observed “it” is not an ontological given, but an effect of form. This insight has important consequences. There is no knowledge independent of form, because knowledge always depends on an indication within a distinction made by an observer. At the same time, the distinction itself is also an indication within another distinction. The inherent paradox of every form lies in the unity of the distinction: the form makes observation possible, but the unity of what it separates cannot be fully observed while the distinction is being used. A paradox-oriented perspective keeps this visible as a condition of observation.

All forms therefore carry an inherent paradox as a structural feature. They make observation possible, while the distinction that enables observation cannot be fully observed at the same time as it is being used. Making this paradox visible, as attempted in this article, may allow for a shift from a coherent understanding toward a paradox-oriented understanding of self-care. A difference that makes a difference.

From this perspective, self-care can be observed as a form. In a systems-theoretical view, forms organize reality. Knowing systems—such as professional care systems or psychic systems that may be described as subjects—do not simply observe problems as they are. They make problems visible through distinctions and subsequent indications. In the case of self-care, the distinction between self-care and non-self-care makes it possible to indicate certain practices as self-care and not as non-self-care. This indication marks relevance. Practices such as rest, recovery, boundary setting, occupational balance, or health management can become observable as caring for the self. At the same time, the other side of the distinction remains in the background. The system observes self-care, while the distinction through which self-care becomes observable usually remains unobserved in the moment of its use. The question that self-care is being distinguished from non-self-care—and not, for example, from conference attendance—remains unobservable in the moment the distinction is used. Once self-care is marked as relevant, non-self-care is carried along as the negative side of the form. Insufficient self-care becomes implicitly observable at the horizon of the distinction. Professional exhaustion can then be interpreted as a sign that self-care is needed. A lack of energy, motivation, balance, or emotional availability may appear as evidence that the practitioner has not cared sufficiently for the self. In this sense, the distinction may help produce the very deficit to which self-care responds.

Toward a Paradox-Oriented Understanding of Self-Care

As indicated above, a shift from coherence-oriented thinking to a paradox-oriented understanding may change how self-care is approached. From a form-theoretical perspective, the paradox of self-care cannot be solved without being displaced into another distinction. Rather, the task is to work with it reflexively ² : to observe how self-care observes, under what conditions self-care becomes observable, and how self-care reproduces the conditions of its own possibility. In this way, the form of self-care may open up additional possibilities for protecting the capacity to care while also observing the expectation to remain capable of caring as part of the problem.

From a practical perspective, this changes how self-care is approached. Self-care may no longer be treated as a simple remedy for professional exhaustion, but as a practice whose conditions and consequences remain visible. For occupational therapy practice, this means resisting the immediate translation of exhaustion into individual responsibility. Practitioners may need rest, recovery, boundaries, and meaningful occupations. At the same time, their exhaustion may also indicate high emotional capacity demands or organizational cultures that normalize overload. Reflexive self-care therefore asks three questions: What does this practitioner need? What conditions make this need necessary? And what is reproduced by observing this need through self-care?

This also means recognizing that self-care does not merely respond to stress; it may also help stabilize stress as a professional reality. Once exhaustion is repeatedly communicated as a reason for self-care, stress becomes part of how the profession observes itself and how practitioners may come to understand their own professional situation. In this sense, self-care can make stress visible, but it can also reinforce stress as an expected background condition of occupational therapy work.

For education, this means teaching self-care as more than a personal competency. Students and new graduates may learn strategies for sustaining themselves, but they may also learn to observe the expectations attached to these strategies. They may learn how the very concept of self-care can add another layer of care responsibility and thereby reproduce the condition that self-care seeks to address. For organizations, this means treating self-care not as a substitute for structural responsibility. Wellness initiatives, mindfulness programs, or resilience trainings may support practitioners, but they cannot compensate for working conditions that repeatedly produce exhaustion. If self-care is constantly needed, this is not only evidence of individual vulnerability. It is also information about the system in which practitioners work.

A paradox-oriented approach therefore keeps both sides visible. Self-care can be a solution and a problem. It can be supportive and demanding. It can protect practitioners and make them vulnerable at the same time by individualizing systemic problems. The point is not to choose one side of the distinction, but to observe how both sides are reproduced through the form of self-care.

In this sense, self-care becomes reflexive when it observes its own conditions and consequences. It supports practitioners not only by encouraging them to care for themselves, but also by allowing them to question when care itself has become too expansive or when the distinction itself has become part of the problem. Reflexive self-care includes the ability to care, to set limits to care, and to suspend the observation of everything through care.

Conclusion

We have argued that self-care is inherently paradoxical. It addresses professional exhaustion by extending the care imperative to practitioners themselves. In doing so, it may relieve strain while also adding another layer of care work. Self-care can therefore respond to organizational load by expanding the demands it seeks to address.

A reflexive understanding of self-care keeps this paradox visible. It observes the organizational and systemic conditions under which self-care becomes necessary, while also attending to the consequences of framing exhaustion as a self-care problem. In a paradox-oriented understanding, this visibility expands the range of possible responses available to practitioners.

Self-care may therefore include more than caring for the self. It may also include setting limits to the care imperative itself. Sometimes, the most caring act may be the capacity to say: I don’t care.