Clinical Impact Statement: The demands and challenges in psychotherapists’ professional and personal lives can contribute to decreases clinical competence and ethical decision-making. This article explains how the use of colleagues for input and support can be very effective in promoting ethical and effective clinical practice.
The practice of psychotherapy is typically, by its very nature, a solitary activity for the psychotherapist. Even for those psychotherapists who work in group practices, hospitals, clinics, and other similar settings, the individual nature of the practice of psychotherapy can be isolating. The one-on-one nature of most psychotherapy and the demands placed on the psychotherapist due to confidentiality requirements add to the isolation one may experience. For psychotherapists in private practice, this can be even more pronounced. Yet, even when there are colleagues in one’s practice setting, it is easy to become focused on direct client care, seeing clients hour after hour, and not taking the time to interact with colleagues. Brief breaks between treatment sessions and lunch breaks (if one takes them) may be used to keep up with documentation requirements, checking and responding to e-mails, listening to voicemail messages, and returning phone calls. Confidentiality requirements make it difficult to share clinical challenges, leading psychotherapists to keep all that transpires in their interactions with clients and the personal impact of these experiences to themselves.
Financial pressures, such as from decreasing reimbursement rates from managed care, can push psychotherapists to see more clients each day. Even for those in fee for service practices, financial and other pressures may exist that can make taking time for oneself more challenging. It has become increasingly difficult for interactions with colleagues to occur on an ongoing basis, perhaps adding to psychotherapists’ feelings of isolation. Professional isolation can be detrimental to one’s professional competence and can contribute to the development of distress, burnout (Baker, 2003), and problems with professional competence (Elman & Forrest, 2007). As will be described in this article, professional isolation can contribute to difficulties with ethical decision-making and can lead to increased risks of unethical conduct occurring. Recommendations for preventing and addressing these challenges are provided.
Competence is defined by Haas and Malouf (2005) as possessing the necessary knowledge, skills, attitudes, and values to effectively provide needed professional services, and having the ability to implement them effectively. Competence is required of psychotherapists by their profession’s ethics code and it is essential for the provision of effective treatment services to clients. Yet, competence is not static and is easily impacted by the presence of distress in the psychotherapist (Dunning, Johnson, Ehrlinger, & Kruger, 2003). It also is vulnerable to degradation over time due to changes in one’s field and from lack of practice of certain skills; thus, ongoing efforts must be made to stay current with recent developments in the field, to keep one’s skills sharp, and to prevent professional and personal stressors from negatively impacting one’s competence (Neimeyer, Taylor, Rozensky, & Cox, 2014). Because of the direct impact on the quality of care clients receive, these authors emphasize the ethical imperative of ensuring that one’s ongoing competence is maintained. Yet, realizing when one’s competence is at risk and knowing what corrective actions are needed can be a challenging task for even the most thoughtful psychotherapist.
Ethics codes require psychotherapists to self-monitor their competence and the effects of any ongoing threats to it. For example, Standard 2.06, Personal Problems and Conflicts, of the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA], 2017) requires psychologists to monitor their personal functioning and to take corrective action “when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner” (p. 5). Yet, self-monitoring and self-awareness, while important, are generally insufficient for ensuring ongoing professional competence. Numerous studies demonstrate that health professionals are poor at accurately assessing their own competence (Davis et al., 2006). In fact, research shows that the more impaired one’s functioning is, the more impaired one’s ability to accurately assess it is, as well (Kruger & Dunning, 1999).
Professional isolation can contribute to difficulties with ethical decision-making and place the psychotherapist at greater risk of engaging in unethical behaviors (Cooper, 2009). Psychotherapists may be isolated by choice, such as when surrounded by colleagues but choosing not to engage in any ongoing relationships with them. Alternatively, some psychotherapists practice in rural and other isolated areas where there may be few colleagues available. In these settings psychotherapists may need to pursue collegial relationships with members of other health professions in the local area, and they may need to establish long distance collegial and mentoring relationships with colleagues via the telephone or internet.
Colleagues can provide emotional support, serve as a sounding board, offer practical advice and suggestions, provide consultation when clinically challenging situations arise, and help manage the stresses of psychotherapy practice. The act of getting out of the office and interacting with colleagues can be important for promoting one’s competence and wellbeing. Knapp and VandeCreek (2012) found that psychologists who are members of their state psychological associations have a reduced risk overall of disciplinary action by regulatory boards. Of course, just paying dues to maintain membership in one’s professional association is not sufficient. Rather, active engagement with others, participating on listservs, attending continuing education and social events (getting out of the office and interacting with colleagues), and the like are important for reducing professional isolation and promoting ongoing competence. Active participation in one’s professional association can lead to forming a network of colleagues with whom one can consult when faced with ethical dilemmas and clinically challenging situations, and who can serve as resources when making referrals for clients whose needs fall outside one’s areas of competence (Allot & Lloyd, 2009).
Self-Care, the Promotion of Wellness, and Competence
In addition to generally being isolating (a stressor in its own right) the practice of psychotherapy can be an emotionally taxing and demanding endeavor. We may work with clients suffering from chronic conditions who do not improve—and for those who do, some may experience relapses. Clients may be aggressive or violent and some may engage in self-harm, life-threatening behaviors, and even suicide, which Baerger (2001) describes as “emotionally devastating” for clinicians (p. 359). When treating clients who are victims of trauma, psychotherapists may experience vicarious or secondary trauma (Figley, 1995). Clients may be uncooperative with efforts to assist them, they may discontinue treatment prematurely, they may refuse to pay for services provided, and may file ethics and licensing board complaints or law suits. In addition, there are stresses and challenges associated with the business aspects of practice with which psychotherapists must contend. Finally, each psychotherapist has unique personal life challenges and stressors, such as those involving relationships, health (and mental health), and financial issues.
While the practice of psychotherapy can be tremendously rewarding and gratifying, each of the factors mentioned above, along with many others, can make it a challenging and stressful endeavor (O’Connor, 2001). In combination with other life events, this can lead to the experience of distress, the subjective emotional response to challenges that each psychotherapist will experience at various times. While distress does not imply decreased competence, as Baker (2003) describes, distress left unchecked can develop into burnout and, over time, result in reduced professional competence.
Eventually, failure to adequately manage and respond to these various stresses can result in psychotherapists experiencing emotional depletion, disrupted personal relationships, loneliness, anxiety, and depression (Johnson & Barnett, 2011). Continued practice under these circumstances can result in a decrease in competence and is not consistent with the ethical responsibility for mental health providers to take corrective action when “personal problems will prevent them from performing their work-related activities in a competent manner” (APA, 2017, p. 5).
Thus, it is vital that each psychotherapist engage in ongoing self-care and the promotion of wellness. While the specific self-care practices used are up to the individual psychotherapist, they can be especially effective when they include a social or relational component. Many of each individual’s needs are relational, and the use of colleagues can be especially helpful in our efforts to promote ongoing wellness and effective functioning.
Communitarianism and Professional Competence
As Johnson et al. (2014) observe, “ethics standards and regulatory policies in psychology frame competence as an individual responsibility” (p. 212). Yet, as these authors propose, it is only through effective interaction with others that psychotherapists are able to practice ethically and competently. Additionally, while self-monitoring and self-awareness are regularly emphasized in ethics codes and professional practice standards to promote ethical practice, due to psychotherapists’ flawed self-assessment overall (Dunning, Heath, & Suls, 2004), being solely responsible for one’s self-assessment and for developing one’s own response plan when difficulties arise is highly problematic and not likely to be effective.
Johnson, Barnett, Elman, Forrest, and Kaslow (2012) recommend replacing the current individualistic approach to professional practice with a communitarian, collectivistic, or interdependent one. As they state: “When communities of psychologists accept responsibility for supporting the functioning and professional competence of colleagues, problems of professional competence will be less frequent and less likely to harm consumers, the profession, and psychologists themselves” (pp. 557-558). In essence, psychotherapists must look out for each other and must actively utilize each other in their efforts to manage the various challenges and stresses in their lives, taking a proactive and preventive approach to defending against ongoing threats to their competence.
In addition to the above, the process of aging can bring with it decreases in functioning and effectiveness that can be difficult for individual psychotherapists to accurately assess. While some professions have a mandatory retirement age (Tarkan, 2011), licensed psychotherapists are authorized to practice their entire lives unless a complaint is filed. They have sole responsibility for monitoring and evaluating their own functioning, and for deciding when they “should” retire from practice (Guy, Stark, Poelstra, & Souder, 1987).
It is hoped that it is evident that this individualized approach to self-monitoring and independent decision-making is not optimal. Johnson, Barnett, Elman, Forrest, and Kaslow (2013) recommend creating competence constellations: networks of colleagues and others who interact and rely on each other on an ongoing basis. It is by being there for each other and by taking responsibility for ourselves and for our colleagues in these caring networks that we have the best chance of addressing these needs through emotional and operational mentoring, feedback, and support.
It is recommended that all psychotherapists pursue the development of, and actively participate in, their own competence constellation. By actively engaging with colleagues in an open, honest, and transparent manner, psychotherapists may receive the support and assistance needed to more effectively manage the many challenges, stresses, and difficulties they face in their professional and personal lives. By being there for colleagues as an active part of their competence constellations, psychotherapists have the opportunity to assist and support these colleagues while benefitting from participation in meaningful reciprocal relationships.
An example of one aspect of a competence constellation is the peer support/consultation group. This involves a group of colleagues who meet regularly to discuss various issues and challenges in a supportive and accepting environment. Over time, each participant will have the opportunity to serve in both sharing and caring roles with these colleagues. While clinical consultations may occur, the group is not limited to this. Members may share about successes and sources of pride in their lives along with challenges, dilemmas, stresses, and frustrations. Participation in such a group will hopefully reflect a more communitarian and interdependent approach to being a mental health clinician, resulting in more effective responses to threats to one’s competence.
Ethical Practice as an Interpersonal Activity
As has been highlighted, psychotherapists regularly face ethical dilemmas and challenging clinical situations. Knowing the best course of action to take is not always a simple proposition and is not always readily evident. Additionally, as has been pointed out, when one’s competence is degraded, the ability to accurately assess one’s competence, including one’s ethical decision-making and judgment, may be degraded as well. Risk management experts recommend several key strategies to promote ethical practice and to help minimize risk. These include informed consent, documentation, and consultation (Knapp, Younggren, VandeCreek, Harris, & Martin, 2013).
Consultation is described as an essential component of ethical practice. No psychotherapist can have all the answers at all times. Seeking input from colleagues can provide different perspectives on a challenging situation or dilemma, opening one’s mind to options and alternative courses of action that had previously not been evident. From a risk management perspective, consultation with colleagues demonstrates an acknowledgement of the complexities of a client’s treatment and a recognition of the need for input by others to best address the client’s treatment needs. The use of consultation also demonstrates an understanding that one’s competence is finite and that the assistance of experienced colleagues can augment one’s limited competence. It also demonstrates appropriate humility in that we don’t know what we don't know, as well as one’s commitment to provide clients with the highest possible quality of care.
Consultation is also found as one of the essential steps in a wide range of ethical decision-making models (Barnett & Johnson, 2008, 2011; Cottone & Claus, 2000) that are suggested for use when psychotherapists are confronted by ethical dilemmas and challenging clinical situations. The inclusion of consultation with experienced colleagues in such a wide range of decision-making models acknowledges the need to not attempt to work through such challenges on one’s own and that effective ethical decision-making is not a solitary activity. Additionally, as has been highlighted, a communitarian approach to addressing the many stresses and challenges in one’s professional and personal lives further reinforces the point that to practice ethically and competently, one needs active engagement with colleagues on an ongoing basis.
Psychotherapists (and psychotherapists-in-training) must see themselves as part of a larger network and recognize that active participation in this network is essential for maintaining their fragile competence throughout their careers. Rather than focus on independent functioning and responsibility, there is a need to train psychotherapists to seek input and care from colleagues and to see their own roles in providing this to their colleagues. This focus on interdependence should help promote professional competence among psychotherapists at each stage of their lives and careers.
The mental health professions need to infuse a communitarian approach to ethical practice and competence into each student’s training and integrate a focus on competence constellations as an essential obligation of all mental health professionals.
Educators and supervisors will need to engage in these practices themselves, modeling them for their students and trainees, helping to normalize this culture of reciprocal caring as an essential aspect of each psychotherapist’s professional identity. The importance and role of competence constellations should be integrated into all aspects of graduate training, both in relevant academic coursework and in clinical supervision.
The APA Ethics Code (APA, 2017) and the ethics codes of the other mental health professions need to be modified to move away from their historic individualistic approaches. A focus on communitarianism and caring for each other should be infused throughout their standards. Examples include the following italicized additions to these standards, as suggested by Johnson and colleagues (2012):
Standard 2.03, Maintaining Competence: Psychologists undertake ongoing efforts to develop and maintain their competence. Psychologists maintain regular engagement with colleagues, consultation groups, and professional organizations and routinely solicit feedback from these sources regarding their competence for work in specific roles and with specific populations.
Standard 2.06, Personal Problems and Conflicts: (c) When psychologists become aware that a psychologist colleague is experiencing problems that may lead to interference with professional competence, they offer care and support, and collaborate with that colleague in assessing competence and determining the need to limit, suspend, or terminate their work-related duties.
It is hoped that such sentiments will be integrated into each psychotherapist’s professional identity. Doing so should go a long way toward promoting ongoing competence despite the many challenges one may face throughout one’s career. But, there is no need to wait for the APA and other professional organizations to revise their ethical standards. Each psychotherapist should take positive actions now to engage with colleagues in supportive and caring communities to promote personal and collective wellness, competence, and ethical practice. It is essential that psychotherapists combat and overcome the urge to isolate themselves and attempt to manage the challenges of being a psychotherapist on their own. After all, the only way we can truly practice ethically and competently over time is with the input, support, and guidance of each other.
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