Imagine: You’ve been in an accident. Now, your thinking is clouded and unclear, you are terrified that you have lost your ability to reason and think clearly and it might never return, and you have a caseload of clients. What would you do? If you didn’t (or couldn’t) turn to anyone, is there someone in your life who would see what was happening and help you? What, as a profession, should we do if someone in this very situation were to see clients and commit an ethical violation, all because they did not have the cognitive capacity to reason a good solution until it was too late?
Halfway through the summer quarter of my graduate training, I sustained a concussion and my world fell apart. I had clients at the student clinic, a full course load of classes, and had just started a new externship; yet I could not drive, could not use a computer, could not regulate my emotions, and could not think clearly. Injured, frightened, and vulnerable, my instinct was to throw all my resources into maintaining a façade of competence. I knew that I needed help, but could not figure out how to get it and kept hearing myself tell people that I was “fine.” Luckily, as a graduate student I had a safety net built into my life and clinical work in the form of my supervisors and professors, and with their help was able to cancel or postpone my clinical and academic responsibilities.
Ethical concerns related to competence have been raised since the beginning of psychotherapy. However, it was not until 1987 that the APA regularly began to use the term “impaired psychologist,” and it was not until 1992 that the word “impaired” was included in the ethics code (APA, 2006; O’Connor, 2001). Today, there is abundant research related to clinician impairment, or interference in the professional functioning of psychologists, due to factors such as burnout, vicarious trauma, and personal stressors (O’Connor, 2001; Smith & Moss, 2009). However, the issue of cognitive impairment has been mostly overlooked. For example, when Members of the APA Board of Professional Affairs’ Advisory Committee on Colleague Assistance (2006), examined interference in the professional functioning of psychologists based on 12 categories or causes, cognitive impairment and impairments arising from injuries or illness were never mentioned. Additionally, while cognitive impairment certainly falls under various standards within the APA Ethics Code, nowhere is it directly addressed (APA, 2010). An August 2014 review of the literature yielded no results that directly address interference in the professional functioning of psychologists due to physical causes or cognitive impairments, and although various materials from the APA and other sources relate to collegial assistance, no direct guidance appears to exist regarding the ethical management of cognitive impairments (APA 2006 & 2010; O’Connor, 2001; Smith & Moss, 2009). This gap in the literature and APA guidelines is particularly striking as a cognitive impairment has the potential to interfere with the psychologist’s ability to follow the ethics code, solve problems, and seek appropriate assistance.
Psychologists are trained regarding the ethical implications of many challenging situations, ranging from what to do if you have a personal crisis and cannot manage your professional role to how to handle romantic feelings for a client. But how many are asked: What if something happens that impairs your very ability to navigate ethical issues? Given that an average of 1.7 million people sustain some form of traumatic brain injury (TBI) annually in the United States (Centers for Disease Control, 2006), it is worth considering how many of these may be mental health professionals, and what unique challenges these individuals may face. It was almost overwhelming how many psychologists and therapists reached out to me with comfort and stories of their own experiences of having had mild-moderate TBIs. Many of these people, like me, struggled to manage their professional and clinical responsibilities as they sought to evaluate their own competence while their ability to complete such an evaluation was impaired. Now mostly healed, I continue to think about what might have happened if I had not been a student and did not have the network of support and oversight upon which I relied.
It is clear that there is a high prevalence of TBIs and a lack of research and concrete guidance for how they should be ethically managed in professional psychology. However, merely understanding and illuminating this problem on an intellectual level is not enough. Facts and concepts often fail to capture the rich complexity of the human experience. With this in mind, I would like to share my story in the hope it may bring this problem to life, remain salient long after the facts presented have been forgotten, and possibly help someone who has found—or will find—themselves in a similar situation.
It was a Saturday morning, and to revive myself from the pressures of graduate training I was out riding horses with my friends. As the powerful mare I rode increased her stride, accelerating to a gallop, she tripped. Together, we catapulted into the ground. I felt my head hit, saw the horse’s body rolling over me, and the next thing I knew the horse was gone and I was lying on the forest floor.
After my fall, I was able to slowly get to my feet. My friends had come back to help me, and the horse, having landed on a soft, squishy human, was fine. They asked what had happened and tried to ascertain if I was okay. I had trouble hearing them, but, seeing the mouths moving and being able to make a good guess at their questions, I managed to answer appropriately. My ears ringing and head spinning, I clambered back onto the horse. It took every ounce of my concentration and ability to stay on as I fought back my dizziness, nausea, and disorientation, but somehow I made it back to the trailhead. With no one aware of how badly injured I was, and doing everything in my power to present myself as tough and competent, I got in my car and drove home.
I am still shocked that I made it home safely. My peripheral vision had shrunk to nothing (I had about 90° of vision), and it took all of my focus to keep my car on the road, following the car in front of me. I knew that I shouldn’t drive, but couldn’t figure out how to avoid it. I remember thinking that I should call someone to help me, but couldn’t resolve the dilemma that it would be even more dangerous to try to talk on my phone while driving. Pulling over to make a call simply never occurred to me.
The first time I looked at a street sign, I was shocked. The words were meaningless, indecipherable scribbles to me. It took about 24 hours before I was able to decipher writing again, and weeks before I could reliably read a few sentences.
When I got home, I stubbornly continued to push myself. I could feel my body and mind crashing, but continued to single-mindedly pursue the agenda I had set out for the day. I was scared, but also convinced that if I kept going through the motions of my life, following the script I had written, that I would magically heal. My symptoms continued to increase. A few hours later, even standing had become difficult and I had become abnormally irritable, picking a fight with my roommate for no apparent reason. Luckily, my roommate is a remarkably kind person who has some awareness of brain injuries, and as I stood there, swaying at the effort of remaining on my feet and yelling meaninglessly at her, she responded with firm compassion and brought me (unwillingly) to the hospital.
I impressed myself with my ability to concisely and clearly explain to the doctors what had happened. Yet, the more I spoke the more concerned they appeared (I’ve never seen a doctor turn that white before), and I became frustrated that they didn’t seem to take my side that everything was going to be fine. When they stepped out, I turned to my roommate, who was loudly not saying anything, and irritably demanded that she tell me what was amusing her. Keeping a straight face—and I could tell this took an effort—she explained that while she could understand what I was saying, I wasn’t conjugating any of my verbs correctly and was randomly leaving words out of my sentences. I laughed.
I passed all the tests, miraculously had no broken bones, and was diagnosed with a concussion. The doctor warned me that I needed to avoid anything mentally strenuous, an order I, a full-time graduate with perfectionism issues, fully intended to ignore and found even more comical than my speech impairment. After all, as a life-long equestrian, I was accustomed to falls and injuries, and had always been able to successfully hop, drag, and will myself back into the saddle.
The next morning, my thinking was still clouded and unclear. It felt like thinking through a dense fog. I was beginning to realize that I was going to need help, and that I was in no condition to see clients. However, I couldn’t figure out what I needed to do or how to handle the situation. Luckily, I had the sense to email my supervisor and the program director. Interestingly, although reading was nearly impossible, my ability to write remained intact. Writing those two short emails took all day as my computer screen sent shards of pain through my eyes and into my brain. I could barely think through a sentence and couldn’t look at my computer screen for more than a few seconds, but, hours later and with my roommate’s assistance, I’d constructed two professional-sounding emails. My supervisors and the program director later helped me form scripts for how to call and cancel clients, and guided me through discussing my injury with the supervisor at my new externship.
By Monday morning, just under 48 hours after my injury, I was able to present myself relatively well. As long as I used a small vocabulary and didn’t try to express anything too complex, no one could tell there was anything wrong with me. As such, I went to class. I stared at my desk to avoid the professor’s PowerPoint and my classmates’ computer screens. As the professor spoke, my confusion mounted. I clenched my jaw and stifled tears as I realized I could not understand the content of the lecture. I spent the next three hours fighting back the terror that I might have lost my mind, my intelligence, that piece of myself which defines me more than any other.
My afternoon class was an experiential class, and that day it started with a guided meditation aimed to help us connect with our values. It soon became apparent that I couldn’t picture so much as a leaf in my mind’s eye, much less a whole scene and storyline. My mind, always so clear and colorful, had turned into a badly tuned, static-filled television screen.
After my first somewhat adventuresome day, I finally swallowed my pride, reined in my stubborn streak, and took the rest of the week off from classes. It was the longest week of my life. I reached a previously unexplored level of boredom as I stared at the walls of my basement apartment. I couldn’t watch television, couldn’t listen to music, couldn’t read, couldn’t understand audiobooks, couldn’t use my computer, and couldn’t even daydream and become lost in a fantasy world of my own making. I was left with nothing but the tangential and distraught thoughts of my damaged mind. And if that wasn’t bad enough, I was caught in riptides of my emotions.
My emotions were erratic, and regulating them became a full-time challenge I was only occasionally successful at. The slightest set-back would send me into hysterical sobs, and then a small victory would catapult me into the highest joy, bouncing off the walls and singing Hakuna Matata (John and Rice, 1994). My poor roommate had to tolerate a socially deprived, emotionally labile, disinhibited shadow of the person she had come to know, someone who latched onto her for comfort, companionship, and distraction the moment she got home. She should be considered for sainthood.
I also had follow-up doctor appointments and meetings with disability services. Our culture’s reliance on technology became painfully clear as I struggled to reach out to people and make arrangements for my injury without using my computer or looking at the screen of my iPhone, and, once this was done, to get to these appointments. It was a nightmare, and I only succeeded with the kindness of friends and strangers.
Eventually, my abilities began to return. When I realized that I could understand an audiobook and listen to it without getting a headache, I cried for joy (I think my roommate might have cried for joy as well!). As I slowly returned to my classes, I was amazed that sometimes I could understand the professor without any trouble, while at other times I was completely lost and confused. My ability to follow a lecture did not seem to be dependent on the complexity of the ideas presented, and as I struggled to figure out some explanation for my incongruous confusion I became aware of the way in which various professors spoke, for there was something about the cadence, rhythm, and speed of people’s speech which made comprehension either infinitely easier or nearly impossible. Finally, six weeks after my injury, I managed to read an article for one of my classes. It was only about five pages and took all morning, but it gave me hope that I might get myself back again. A couple weeks later, I was able to begin writing simple papers again. Piece by piece my abilities and intellect slowly returned over several months.
Over those first few weeks, I learned a lot about empathy and about how it feels to be unable to control your emotions—to feel yourself escalating and be powerless to stop it. It was also surprisingly easy to “pass” through life by simply not calling attention to myself and nodding in agreement when I had no clue what someone was saying to me, and I learned what it is like for someone who struggles cognitively, someone who is acting their way through life and hoping no one will realize how lost and confused they are. Even when I wanted to express what I was going through, it was easier to follow social norms than admit my impairments and ask for help.
I also learned about the impact of the way we speak and use language. My intelligence has always afforded me the comfort and privilege of understanding things regardless of their delivery, and I learned what a true privilege this is and how much of a difference I can make in helping others simply by being conscious of the way I say things.
My inability to complete the mindfulness exercises also taught me a valuable lesson. I have always loved mindfulness work, and my mind has, for the most part, cooperated with the various meditative exercises I’ve thrown at it. Yet, for the first couple weeks after my concussion, I could no more meditate than fly, could no more visualize a peaceful lake than become one. I wonder how many lower functioning and brain-injured clients struggle with mediation and visualization, and how many times I’ve responded as a therapist by thinking they were being resistant instead of being compassionate to their struggle.
However, the biggest lesson from my concussion was a lesson in ethics. In the midst of my injury, I often could not figure out how to do the right, ethical thing. When I did know what I should do, I often could not do it without assistance. I managed to dodge unethical and dangerous situations only with the help of my friends, supervisors, and professors. There was the professor who told me to go home when I showed up to her class exhausted and struggling with a concussive headache, the supervisor who forbade me from coming to supervision or discussing seeing a client again for at least three weeks, the friends who reminded me time and again not to push myself and who drove me to doctor’s appointments and to run errands, and so many others who kept me safe and gave me hope.
Throughout my experience, one of the hardest things was not knowing what I could and couldn’t do until I collided with a deficit, and thinking that I was better only to find out that I was still impaired. Overall, I got lucky in almost every way imaginable, from the support I received to my brain’s ability to recover from the trauma it sustained. In reflecting on my experience and the larger issue of cognitive impairment among psychologists, I am reminded that our ethics code includes not only standards, but principles we strive to attain. These principles ask us to remain aware of how personal factors and our physical and mental health may impact others, to establish trusting relationships with other professionals and consult when needed, and to help each other in our quest to be ethical and competent (APA, 2010).
Ethical competency is vital to becoming a successful psychologist and is taught in all APA-accredited programs to meet the competency benchmarks for professional psychologists (APA, 2011). However, it is not an easy thing to teach, for learning to become ethical requires not only an understanding of the ethics code, but ability to think critically about challenging situations and the possession of insight into personal factors that may impede ethical decision making. While many professors try to include a wide variety of ethical dilemmas and situations in their classes, nowhere was I able to find evidence of psychologist cognitive impairment being presented as a concept for students to discuss. I would love to see this issue illuminated in the teaching of ethics, as well by the APA ethics board and in empirical research.
However, I believe that change happens largely at an individual level. From my own experience, it was through the kindness of individuals, rather than institutional policies, that I received the help I needed. Therefore, my primary goal is to spread awareness of this issue so that, individually, psychologists might be more alert to this issue and better prepared to help themselves and their colleagues. I also believe that, in holding with the ethics code, we should both demand that psychologists have a plan for how they would deal with a cognitive impairment before it happens and treat psychologists who have the misfortune of sustaining one with as much compassion as we possibly can.