TCP Vol. 76, Issue 1 Ethics Column by Adam Fried, PhD
Over the past 20 years, as a field, we have gained a significant appreciation and understanding of the potential negative impact of distress and impairment on our well-being, career satisfaction and longevity, and patient care. Numerous books and articles have urged practitioners to develop and integrate effective self-care routines on a regular basis. It’s clear that distress and impairment can negatively impact the care we provide; for example, we may not be as attentive to client/patient needs or some types of distress may contribute to biases that interfere with care. But the relationship between distress and impairment and ethics is not as clear, especially in terms of how distress and impairment can lead to ethical violations. Numerous board complaints include testimony from psychologists overwhelmed by personal problems or substance issues, which have significantly contributed to serious ethical breaches. Questions often explore whether these situations could have been prevented, as many of these errors likely would not have occurred had there not been substantial distress and impairment. I also wonder how can we as a field, and, perhaps more importantly, as a community of colleagues, address these types of situations?
A fundamental question in ethics has to do with understanding the reasons people engage in unethical behaviors. One answer may be personal distress and impairment, leading to poor decision-making or failing to fulfill ethically required obligations. Of course, distress does not automatically lead to ethical violations, but it may increase the risk. Distress and personal problems may lead to “professional deficits” (Fisher, 2023, p. 143) in situations in which our decision-making and functioning is compromised. It’s not just that patients are not getting the best care, but that there can be serious ethical lapses. These can include work mistakes or other factors that negatively impact our ability to care for patients/clients, missing important deadlines, failing to fulfill basic care responsibilities, not maintaining a continuity of care by frequently canceling appointments, or even working while intoxicated.
Stressors Faced by Psychologists
The APA’s Board of Professional Affairs’ Advisory Committee on Colleague Assistance (2006) described several types of or factors related to distress and impairment in psychologists, including stress, traumatization and burnout (both personal and professional), financial stressors, family issues, divorce and relationship problems, and personal mental health issues, and substance use. Depression, in particular, has repeatedly been found to be a common issue affecting psychologists (Gilroy, Carroll, & Murra, 2002; Pope & Tabachnick, 1994). Many in our field were alarmed at the recent findings published by Li et al. (2022) related to psychologist suicide, especially with regard to longitudinally increasing trends. Additional stressors that affect everyone, including psychologists, described in APA’s latest Stress in America survey included heightened anxiety about political issues, financial pressures, and growing violence and discrimination, especially among marginalized communities (APA, 2022).
Self-Awareness and Assessment
It may be tempting to conclude that these situations can be prevented by psychologists engaging in self-assessment and self-care, but this may be easier said than done. Standard 2.06a of the APA Ethic Code requires that psychologists, “refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them performing their work-related activities in a competent manner.” But how do we know and are we even good at self-assessment? Even signs that may be evident to others may not be clear to the individual. A study by Williams, Pomerantz, Segrist and Pettibone (2010) involving 285 psychologists found that while psychologists were able to make determinations of when depression and substance use may impair another psychologist’s ability to practice, questions remain about our ability to self-assess. As the authors noted in their conclusion, “In actual practice, it is most often the psychologist’s own impairment that he or she must assess. This self-assessment process may differ greatly from the assessment of others, especially in the case of substance use, which can acutely reduce the user’s capacity for insight.” (p. 155).
How do we know when we’re so distressed that it negatively affects practice? Nash and Chapman (2019) noted the difficulty (and perhaps contradiction) in self-awareness when distressed: “As in other health care professions, we are expected to be self-aware of when we are impaired to a degree that we cannot uphold ethical principles and standards in the provision of psychological services and training …” (p. 98). Others have noted how our own biases, including unrealistic perceptions of capabilities, overestimation of competence, and inability to recognize burnout symptoms, may be key barriers in accurate self-assessment (Ledingham, Standen, Skinner & Busch, 2019). In addition, psychologists may be more likely to view burnout and impairment dichotomously, as something one has or doesn’t have, ignoring both the possibility that one’s state can vary depending on circumstances, as well as the dangers of severe stress that may not yet be burnout (Good, Khairallah & Mintz, 2009; Ledingham, Standen, Skinner & Busch, 2019).
Barriers to Getting Help
Nash and Chapman (2019) uniquely and persuasively illustrated ways in which psychologists may be “… professionally and personally struggling behind masks of competence” (p. 98). How do we create a culture not just self-care but also one that removes the stigma, shame and the negative punitive consequences to encourage psychologists to seek help before significant ethical breach or even a negative impact to care may occur? Addressing these powerful barriers may allow a psychologist, as Nash and Chapman put it, to “be ‘seen’ as both a competent professional and person struggling through a significant life transition” (p. 105), which may be critically important in terms of seeking support.
Many psychologists may find it difficult to disclose to others due to shame and embarrassment, especially situations that are more societally stigmatizing (Charlemagne-Odle, Harmon, & Maltby, 2014). Other barriers include denial of problems, lack of time, financial concerns (especially among younger psychologists), difficulty finding resources, and concerns about confidentiality (including fears about reputation and professional status; Bearse, McMinn, Seegobin, & Free, 2013; Good, Khairallah, & Mintz, 2009). Finally, fear of being seen by others as incompetent may also prevent psychologists from confiding in other professionals and seeking necessary help (Vierthaler & Elliott, 2020).
Notwithstanding these barriers, many psychologists would agree that therapy would be helpful for them. In a study of 260 psychologists, Bearse et al. (2013) found that while most psychologists have participated in some therapy, the average amount of time since the respondents’ last therapy session was almost 13 years. Moreover, almost 60% in this sample said that there were times when therapy would have been helpful but they did not pursue it.
Talking with Colleagues
Despite their area of expertise, psychologists may feel they are not in a position to intervene with colleagues (Smith & Moss, 2009) and may be more likely to report colleagues to governing bodies instead. Why is this the case and how do we facilitate professional outreach? As a profession and articulated in the APA Ethics Code (2017; Standard 1.04), we attempt to resolve issues informally when appropriate, which may include initiating a conversation, coming from a place of a concerned and caring colleague. Reasons that psychologists may not express concerns about a colleague’s behavior may include concerns about whether they have enough evidence to raise concerns, questions about their role and obligation in discussing concerns, fear of adverse outcomes, including to themselves or their colleague, and beliefs that the concerning behaviors do not affect the colleague’s professional practice (Johnson et al., 2008, 2011).
It can be difficult telling a colleague, no matter what the profession, that there are concerns about their ability to carry out their professional duties. This is true in most fields, although mental health professionals probably understand the barriers to seeking help better than most and have skills for which we receive extensive training; these include communicating with empathy and nonjudgmental concern, providing support, and facilitating problem-solving. Kleespies et al (2011) and O’Connor (2008) offer helpful and specific recommendations for intervening with a colleague who may be distressed or experiencing impairment.
It goes without saying that we as a profession should encourage, normalize and facilitate accessible ways to seek help for personal problems. This is not just to help and support our fellow colleagues (although this reason alone is sufficient) but also to prevent perhaps avoidable ethical mistakes and potential harm to patients/clients, as well as more dire consequences, including those that may include severe impacts to one’s career, such as license removal (Nash & Chapman, 2019). On this latter point, it’s important to note that some licensing boards and state psychological associations have voluntary colleague assistance programs for psychologists who are experiencing distress in ways that may impact their practice, although some of the aforementioned barriers may impact use of these types of services (Barnett & Hillard, 2001; Munsey, 2006).
Honest conversations informally, through organized mechanisms such as peer consultation groups, and through publications, about our own struggles may help to normalize these experiences and start critical conversations [see Vierthaler and Elliot (2020) and Nash and Chapman (2019) for informative and powerful examples]. Removing barriers to having difficult conversations and admitting when there are times when personal issues may be having a significant impact on professional practice can allow for compassion, connection, and care, rather than judgment and isolation.
In their eloquent commentary, Good, Khallibrah, and Mintz (2009) highlighted the divide that often prevents us from reaching out to others or even being perceived as open to others seeking help from us. As they note, “…we are all fallible human beings doing the best we can on this journey through life …We will all experience struggles and impairments over the course of our lives. Wellness and impairment is not an ‘Us and Them’ issue; rather, it should be viewed as an ‘Us and When’ issue.” (pp. 22-23).
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