Welcome to ‘CE Corner'
"CE Corner" is a quarterly continuing education article offered by the APA Office of CE in Psychology. This feature will provide you with updates on critical developments in psychology, drawn from peer-reviewed literature and written by leading psychology experts. "CE Corner" appears in the February 2012, April, July/August and November issues of the Monitor.
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CE credits: 1
Exam items: 10
As a result of having participated in this continuing education program, participants will be able to:
- Understand the most common responses to life-threatening illness.
- Describe the limitations of self-monitoring competence during personal illness.
- Articulate strategies for assessing and enhancing competence when responding to one's own life-threatening illness or that of a colleague.
Though we may not like to admit it, psychologists are similar to their clients in at least one important way: We, too, encounter stressful situations that can rock us to the core. We are not immune to being overwhelmed by work, breaking up with significant others or being victims of thoughtless accidents.
Also like everyone else, sometimes we get sick. At some point, nearly every mental health professional will confront a significant health problem. Just look at cancer and heart disease: 13 percent of Americans age 45 to 64 have some form of heart disease and 9.4 percent have been diagnosed with cancer, according to the Centers for Disease Control and Prevention. As our age increases, so does our risk of acquiring such illnesses: 25.8 percent of Americans age 65 to 74 have heart disease and 22.5 percent have been diagnosed with cancer. And, of course, those are just two of the many life-threatening illnesses we face.
Because many psychologists expect to work beyond the typical retirement age — with nearly a fifth saying they plan to work until they die (Guy, Stark, Poelstra, & Souder, 1987) — the probability of life-threatening medical diagnoses during the course of one's career is significant. Unfortunately, despite their training, psychologists are not always effective when it comes to accepting their own vulnerabilities or taking time for self-care. And in times of emotional or physical distress, we may not be able to see that we are no longer the competent professionals we need to be (Barnett & Johnson, 2008).
In this article, we present an overview of the research that explains why seriously ill — and consequently distressed — psychologists may be ineffective at assessing and monitoring their professional competence and determining whether they should stop working. In addition, we recommend ways psychologists can prevent and manage the threats to their competence that may come with life-threatening illnesses.
Common reactions to a life-threatening illness
Many terminally ill psychologists have good reasons to want to continue working. They genuinely love their careers, care deeply for their clients, reap the benefits of being mentally engaged in their work (and distracted from physical problems) and fear that they need to work to pay for medical costs and ensure their financial survival (DeMarce, 2007; Guy & Souder, 1986; Schoolman, 1988).
Research has also identified three particularly compelling reasons to work despite illness: better well-being, reduced anxiety and depression, and easier adjustment to disease progression (Henderson, 1984; Rolland, 1984).
But psychologists — whether healthy or recently diagnosed with a terminal condition — have an ethical obligation to remain cognizant of their competence and to stop practicing when they are no longer adept at doing so (APA, 2010). Despite our training and best intentions, the literature points to four factors that interfere with psychologists' ability to see when they are no longer able to competently practice: emotional distress, denial, fear and countertransferential reactions. The following hypothetical cases shed light on these factors.
Case #1: Emotional distress
At age 52, Myrna, a counseling psychologist, began to experience an unusual weakness in her hands and feet. At night in bed or when sitting still during a counseling session, she began to notice subtle muscle twitching and unpleasant cramping. Although she first attributed the symptoms to stress and caffeine, they worsened, prompting Myrna to see her physician.
After a month of lab work and nerve testing, Myrna received the devastating diagnosis of ALS (Lou Gehrig's disease). She was told that people at her stage in the illness typically lived no more than two to four years.
Although unprepared and unwilling to quit her job as a supervising psychologist in a mental health clinic, Myrna found herself struggling with a rapidly shifting collage of emotions. Throughout a week, a day or even a single counseling session, she could find herself struggling with intense grief, anger, fear and numbing shock. Although vaguely aware that she was less attentive and present with her clients, the depth of her distress and ambivalence about losing her professional life led her to feel immobilized and unable to determine how best to proceed.
Although distress doesn't necessarily result in psychological impairment or problems with professional competence (O'Connor, 2001; Smith & Moss, 2009), there is a positive correlation between them. Dire medical news and the evolution of a life-threatening medical condition can create profound personal distress; psychologists who typically see themselves as strong, competent and in control may be quite unsettled by feeling weak and vulnerable (Guy & Souder, 1986).
Psychologists may also find that while medical events are moving quickly all around them, their own process of psychological adjustment moves more slowly (DeMarce, 2007; Rolland, 1984). Emotional distress about a terminal diagnosis may even interfere with the psychologist's normally keen awareness of his or her level of competence. It is understandable that anyone struggling for safety and survival will have less motivation for pursuing higher-order needs linked to professionalism and self-actualization (Maslow, 1987).
Case #2: Denial
When Charles, a clinical psychologist, began to lose weight, a few colleagues in his group practice congratulated him on his commitment to diet and fitness. But as months passed, Charles continued to lose weight and began to look gaunt and fatigued. When the same colleagues expressed concern, Charles admitted that he was being treated for cancer but that his prognosis was excellent. But as the weeks passed, Charles began to cancel sessions with greater frequency. His colleagues were shocked when they received word that Charles had died of pancreatic cancer. He had informed no one of the serious nature of his diagnosis, nor did it seem that he accepted the terminal nature of his illness himself. Both clients and colleagues were left entirely unprepared for his death.
Denial, the most primitive defense mechanism, may be a psychologist's first response to the diagnosis of a life-threatening condition. Denial may serve to distract and protect the psychologist while he or she works to marshall more constructive defenses and support from colleagues and significant others.
Immediately following diagnosis, denial may enable adaptive performance of necessary duties. But denial may prevent a psychologist from accurately seeing his or her diminished competence. Due to what Barnett (2008) terms "professional blind spots," psychologists may only want to see themselves as helpers. A seriously ill psychologist may be unable to easily shift to seeing him- or herself as one who requires, rather than provides, care.
Case #3: Fear
When Meredith had lunch with her former supervisor, Nora, she was startled by a dramatic change in Nora's demeanor. At 60, Nora was a highly regarded analyst with 30 years in a busy practice. She was known for her quick wit, verbal repartee and delightful humor. But her behavior over lunch suggested dramatic changes in Nora's cognitive ability. She was slow to respond, obviously forgetful and had trouble generating the correct word on several occasions. When Meredith expressed concern, Nora became angry and accused Meredith of being ageist. She said, "I'm 60 for God's sake, everyone has a little trouble at my age." Meredith remembered that during their supervision relationship, Nora had revealed that her mother had died of Alzheimer's disease. She wondered why Nora couldn't see the signs of dementia in her own behavior and wondered what she should do as a concerned colleague.
At times, a psychologist may downplay the impact of difficult medical news or the growing symptoms of a life-threatening disorder out of fear about declining health, professional status, financial well-being and personal and professional independence. The ill psychologist may fear that his or her acumen and judgment may begin to ebb, while simultaneously worrying that colleagues will cease making referrals to him or her (Counselman & Alonso, 1993; Swearington, 1990).
When she was diagnosed with terminal cancer, Claire E. Philip, PhD, wrote, "my reluctance to reach out to colleagues for help on disclosure and practice issues when I was most in shock regarding my diagnosis resulted in a delayed reaction of enormous proportions."
Research indicates that threats to perceived control portend depression and a more difficult disease course (Williams & Koocher, 1998). Psychologists who unconsciously equate illness with weakness may suffer shame and fear that keep them from seeking consultation and taking corrective action when problems of professional competence arise. They might even work to hide symptoms and dysfunction — from themselves and others — in an effort to maintain the appearance of strength, vigor and competence.
Case #4: Countertransferential reactions
As a psychology intern in a children's hospital, Edgar worked with children who had serious, often life-ending diseases. When he received the news that a rare form of brain cancer was the cause of his own failing health, he was adamant that he be allowed to continue his internship half-time while undergoing chemotherapy and radiation in the same hospital. He insisted that his clients and their parents were particularly sensitive to issues of loss and grief and he did not want to abandon them during their treatment. He appeared unreasonably rigid about preventing any family from discovering his illness, and if they did, he sidestepped their efforts to discuss it with him and express their own genuine concerns. Edgar's supervisor reflected that it might be Edgar, not his clients, who might be unprepared to deal with his diagnosis.
Counselman and Alonso (1993) observed that "patients like to see their therapists as invincible [and] it is very tempting for therapists to agree with this flattering view, and to deny their own vulnerability to illness, aging and inevitable death." A diagnosis of a life-threatening condition may trigger defensive countertransference reactions in psychologists who might strike a pose as hero, suffering martyr or stoic parent, ostensibly to protect clients, but actually in an effort to deny their own mortality and delay their need to assess their competence for practice (Rosner, 1986). Acknowledging such vulnerabilities and difficulties "might be seen as inimical to the image of the competent psychologist, and this may then, unfortunately, lead to the exactly opposite effect" (Barnett, 2008).
But how we respond to and address our own illness can be an important opportunity for modeling adaptive behaviors and a healthy response to our clients. It may also provide an opportunity for deep and meaningful sharing between psychotherapist and client. For some clients, the ability to "give something back" to their psychotherapist may be especially meaningful and a therapeutically important step toward their autonomous and effective functioning. Avoiding such discussions may rob the client of these potentially valuable therapeutic opportunities.
Problems with self-monitoring professional competence
Standard 2.06 of APA's Ethics Code states that the psychologist is exclusively responsible for monitoring and addressing problems of his or her professional competence. But when a psychologist is overwrought by a terminal medical diagnosis or experiencing the effects of rapid decline in health, is it reasonable to assume that he or she will be able to self-monitor? Early confusion about the diagnosis and extent of likely incapacitation as well as the psychologist's own denial may keep ill psychologists from accurately assessing their competence (Rosner, 1986). Older psychologists may have similar feelings when they begin to demonstrate cognitive decline.
The problem with self-evaluation extends beyond psychologists who are sick or distressed. A review of studies comparing the accuracy of physicians' self-assessment reveals that most physicians rate themselves more competent than they actually are (Davis et al., 2006). Other social psychology research leads to similar conclusions in most domains of human self-assessment: Self-assessments of both professional skill and personal character tend to be flawed in substantive and systematic ways (Dunning, Heath, & Suls, 2004). Further, people in general tend to wrongly predict how they would respond to emotion-laden situations when they are not currently emotionally aroused (Van Boven, Lowenstein, & Dunning, 2005). Ultimately, self-assessment research suggests that "people tend to be blissfully unaware of their incompetence" (Dunning, Johnson, Ehrlinger, & Kruger, 2003).
If psychologists with serious medical problems are reluctant to seek help from their colleagues (Good, Thoreson, & Shaughnessy, 1995) or for various reasons are ineffective at monitoring their own competence, then perhaps Nancy S. Elman, PhD, and Linda Forrest, PhD, were right in observing that it may "take a village" to address problems of professional competence (Johnson et al., 2008). When psychologists are effectively trained to be members of ethical communities of supportive peers who consult with and watch out for each other, the risk of professional competence problems related to illness should be diminished (Johnson et al., 2008; Kaslow, 2004).
To be effective, such peer networks must overcome several barriers when a colleague is not performing competently. Those barriers include:
- A reluctance to intrude on a colleague's independence or to suggest that he or she may lack current competence;
- Fear that there is insufficient evidence of incompetence to raise the concern;
- Worry that addressing the concern will undermine the relationship with the colleague;
- A lack of clarity regarding one's ethical or professional obligations to intervene;
- Hope that the colleague's difficulties are temporary, linked to recent medical challenges and likely to resolve quickly.
Recommendations for practicing psychologists
So what should psychology practitioners do to reduce the risk of incompetence related to an illness? Recommendations for psychologists fall into two general categories: prevention and response.
In terms of prevention, we encourage psychologists to pursue several avenues of physical, emotional, spiritual and social wellness. Psychologists should:
- Strive for excellent physical fitness, good nutrition, healthy sleep habits and recreation.
- Strike a balance between professional obligations and personal time. Do not take on excessive client loads that interfere with reasonable health and fitness. Set clear boundaries between work and play. Be diligent about scheduling and adhering to time off.
- Regularly engage with significant others, nurture close friendships and make time for rewarding leisure pursuits. • Fully accept your own mortality, make time for routine physical exams and assume responsibility for monitoring key health indicators such as cholesterol, blood pressure and body fat.
- Adhere to medical guidelines and physician recommendations on alcohol consumption, prescription medications, reduced workload or other lifestyle changes.
- Actively plan for sudden or eventual disability. Such planning involves developing a professional will early in one’s career and designating a professional colleague as executor (Barnett & Johnson, 2008), as well as thoughtfully nurturing strong collegial friendships with two or more colleagues. When misfortune strikes, these colleagues should be among the first a psychologist turns to for support.
When a psychologist is diagnosed with a life-threatening illness, we recommend that he or she:
- Seek support. After a difficult diagnosis, people may feel disoriented and have difficulty absorbing the news and planning important next steps. Family, friends and close colleagues can provide immediate and tangible assistance. Resist the temptation to isolate yourself from them, even if this is your instinctive coping style. Remember that the energy you devote to maintaining a veneer of invulnerability is better used for effective coping while accepting others' support.
- Work closely with your physician(s) to ensure you have an accurate and thorough diagnosis and treatment plan. Get second opinions and seek out subject-matter experts to increase your own grasp of the illness and its likely course. Educate yourself about treatment options as a way of feeling empowered. Discuss the prognosis with your health professionals and inquire directly about the likely impact on your professional activities over time.
- Involve one or more trusted colleagues in this process (either individually or through a peer support group if involved in one), asking them to hold the news in confidence. Ask them for support and consultation as you make decisions about medical treatment and how or whether to continue your professional activities (Barnett & Johnson, 2008).
- Remain alert to the impact of your own emotional and physical health status on clients. Recognize that your competence may be diminished as you come to terms with treatment options and prognosis. Consult with colleagues regarding the wisdom of taking a temporary leave from client care and other professional activities, arranging backup coverage as needed.
When the medical picture, including likely course and prognosis, is clarified, consult honestly with physicians, trusted colleagues and significant others about whether to continue, temporarily suspend, reduce or terminate your practice (Barnett, 2008). Take into consideration medical advice, collegial and personal assessments of your competence to practice, and your own preferences for continuing professional work. Concerns about competence should be given preference (APA, 2010).
In consultation with a colleague or two, decide how and when it will be in the best interests of clients and students to hear about your condition. Develop a plan for informing those you serve, recognizing that in smaller communities, news about your health status will reach others quickly. Be alert to the impact your news has on your clients.
Remember that self-assessments of skill are modestly accurate in the best of circumstances and likely to be less accurate when you are emotionally distressed or distracted. That's why you should enlist one or more trusted colleagues to help you monitor your competence during periods of distress and disability. This may take the form of consultation, record reviews, and even reviews of recorded sessions or direct observation, if appropriate and consented to by clients.
If it's appropriate to suspend or terminate your practice, be as active as possible in planning termination with each client or supervisee so that you can ensure that the process serves their best interests (Barnett, 2008; Philip, 1993). Remember to ask yourself, "Who shall I be in the process of ending my professional activities?" (Jordan & Meara, 1990). In suspending or terminating professional activities, it is equally important to "do" the right thing ethically and to "be" a virtuous professional, a psychologist who places the welfare of others first and foremost. Rely on colleagues to help you develop and execute a thoughtful and client-centered plan for termination.
Recommendations for colleagues
When a colleague faces a serious medical condition, psychologists should move swiftly to provide unwavering support and honest consultation (Barnett & Johnson, 2008; O'Connor, 2001). Here are several steps for supporting the colleague in ways that focus on his or her competence and best serve clients:
- Help the colleague accept that all humans are vulnerable to infirmity and all psychologists are vulnerable to distress.
- Frequently check in to offer moral support and personal encouragement. Nudge the colleague to stay connected to avoid his or her isolation.
- Offer to provide honest feedback regarding the psychologist's presentation and affect. When invited, offer advice on the wisdom of continuing to provide services as well as ways to handle professional activities and disclosure to clients.
- Balance collegial support with an effort to protect the interests of those served by the colleague.
In the rare case that a colleague with professional competence problems refuses to hear or respond to recommendations that he or she limit scope of practice or submit to supervision or assistance, consider more formal strategies to resolve the conflict. For instance, if there is evidence that the colleague's competence problems are placing others at risk, contact a licensing board, state psychological association's colleague assistance committee or other appropriate regulatory body (APA, 2010; Barnett & Johnson, 2008). However, even when more formal action is indicated, it is helpful to avoid an adversarial role with the colleague. Firm feedback and steps to protect the public need not necessitate the end of one's collegial role.
We hope that this article offers both useful ethical guidance and a healthy reminder that psychologists are human. All of us will be well served by carefully minding our health, surrounding ourselves with thoughtful colleagues and planning ahead for medical challenges.
W. Brad Johnson, PhD, is a professor in the department of leadership, ethics and law at the U.S. Naval Academy and a faculty associate in the Graduate School of Education at Johns Hopkins University. Jeffrey E. Barnett, PsyD, is a professor of psychology at Loyola University Maryland and an independent practitioner in Annapolis, Md.