PROFESSIONAL VULNERABILITY

PROFESSIONAL

VULNERABILITY

Perfectionism

• Despite cultural sanctions, perfectionism is not adaptive.

• Perfectionism is a vulnerability factor for depression, burnout, suicide, and anxiety.

• The desire to excel must be differentiated from the desire to be perfect.

“The perfect is the enemy of the good.”

- Voltaire

Perfectionism (cont.)

• Believing that others will value you only if you are perfect is associated with both depression and suicide.

• It contains an element of pressure associated with a sense of helplessness and hopelessness.

• “The better I do, the better I’m expected to do.”

• Intense need for external validation

- Flett & Hewitt, 2002

Origin of Perfectionism

• Not well understood

• Multiple pathways are involved:

1. Child factors—temperament, attachment style

2. Parent factors—style of parenting, parental personality

3. Environmental pressures—peers, culture, teachers

Flett & Hewitt, 2002

Origins of Perfectionism (cont.)

• Satisfaction with real achievements is limited because of feelings of fraudulence and the expectations that more will be demanded.

• The “driven” quality is designed to gain relief from a tormenting conscience rather than a genuine wish for pleasure.

Consequences

• Burnout

• Depression & suicide

• Problems with self-care

• Marital problems

• Substance abuse

• Professional boundary violations

Definitions of Burnout

• State of fatigue or emotional depletion brought about by adherence to a professional role that has failed to produce expected rewards

• “An erosion of the soul” - Maslach & Leither, 1997

Definitions of Burnout (cont.)

• “Joyless striving”

- Holmes & Rahe

Symptoms of Burnout

• Failure to take vacations

• Chronic fatigue

• Emotional exhaustion

• Cynicism

Symptoms of Burnout (cont.)

• Headaches, lack of pleasure in relationships

• Increased drinking

• Marital deadness

• Explosions of anger

Midlife Disillusionment

• The pay-off for self-sacrifice never materializes

• Feelings of betrayal and disillusionment

Problems with Spouse or Partner

• Psychology of postponement

• Lives of quiet desperation

• Failure to make time for intimate conversation

Profile of Professionals

• No simple formula

• 20% are female

• 20% are same-sex

• Vulnerability is universal

Common Themes

• Omnipotence –

“Only I can save the patient.”

• “True love” is idealized,

valorized, and mythologized

• The presence or absence of “true love” is irrelevant to ethics considerations

PROFILE OF VICTIMS

• Incest victims (sitting duck syndrome)• Patients with a history of sexual abuse• Attractive patient with chronically low self-

esteem• Patient with a history of previous

hospitalization, suicide attempts, and substance abuse

• Depressed and suicidal patient with recent romantic break-up

Profiles of Victims (cont)

• Borderline Personality Disorder Patients

• Intellectually Challenged Patients

• Drug-Seeking Patients

• First Nation People

• Patients in Lower Socioeconomic Groups

Special Situations

• Rural Practitioners

• Home Care Practitioners

• Multi-Cultural Issues

PRINCIPLES OF ASSESSMENT AND REHABILITATION

• Disciplinary measures are the purview of a College or licensing board, while psychiatric assessment is the purview of independent mental health professionals.

• Treatment recommendations growing out of an assessment, however, must be integrated with the disciplinary stipulations.

PRINCIPLES OF ASSESSMENT AND REHABILITATION (cont.)

• Evaluating team must differentiate between impairment and problems in professionalism.

• In some situations, both may be present.

• Questions from referring College or board are helpful in focusing the assessment.

PRINCIPLES OF ASSESSMENT AND REHABILITATION (cont.)

• Collateral information from complainants, family members, colleagues, police reports, and College are always valuable and often essential.

• Signed release to College or other agency is necessary before beginning the evaluation.

Substance Abuse

• Substance abuse may be a contributing factor that is hidden

• Collateral sources may not know about it

• Random urine drug screen is useful to rule out substance use

• The professional’s response to the prospect of a urine drug screen is highly informative

Principles of Assessment and Rehabilitation (Cont)

• Amenability to rehabilitation must be carefully assessed

• Narcissistic mortification is not the same as genuine remorse

• Risk of repeating boundary violations and the safety of the public must be weighed against practitioner’s wishes

Components of Rehabilitation Plan

• Practice limitations• Chaperone requirements• Mentoring• Supervision• Change of practice setting—group,

institution only• 12-steps programs

Components of Rehabilitation Plan (cont)

• Individual psychotherapy—psychodynamic, cognitive-behavioral

• Marital or couples therapy

• Pharmacotherapy

• Inpatient or residential

• Total duration of plan may be 3-5 years