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Saturday, April 21, 2012

Turning Good Intentions into Good Behavior: Self-perception, Self-care, and Social Influences

Samuel Knapp, EdD, ABPP
Director of Professional Affairs

John D. Gavazzi, PsyD, ABPP
Chair, PPA Ethics Committee

Originally published in The Pennsylvania Psychologist

            Most of us want to fulfill our ethical mandate to help our clients as best as we can. However, non-rational factors, such as faulty thinking habits, situational pressures, or fatigue can overpower our good intentions and lead to less-than-optimal ethical behaviors. We are not just referring to flagrant misconduct that would leave us vulnerable to a licensing board complaint or lawsuit. Instead, this less-than-optimal behavior is more subtle, such as delivering acceptable (but not top quality) professional services.
Traditional approaches to improve ethical conduct and clinical skills involve attending didactic lectures. As helpful as these lectures may be, behavioral change is more likely to occur when we take a more active role in exploring how important variables such as self-perception, self-care, and social factors influence clinical performance (Tjeltveit & Gottlieb, 2010). Reducing our blind spots, increasing our self-knowledge, and enhancing our awareness of work pressures and organizational cultures are worthwhile processes to explore in order to investigate our basic ethical obligations (Bazerman & Tenbrunsel, 2011).
Professional narcissism,” or an “overestimation of one’s abilities” (Younggren, 2007, p. 515) represents one such blind spot. For example, Davis et al. (2006) asked physicians to perform a standardized patient procedure, and then estimate their competence at that procedure. Most physicians rated themselves higher than justified, including a few who performed incompetently but nonetheless rated themselves very high. While a modest amount of overconfidence may be harmless (or perhaps even healthy), we need to guard against the tendency to see ourselves as much better than we really are. We can avoid professional narcissism through activities that promote self-reflection, such as keeping a journal geared toward clinical experiences and contemplating ethical nuances of practice. We can also establish routines to ensure regular feedback about our behavior, such as asking patients questions at the end of sessions. We can ask how the session went or how we could have been more helpful. Some psychologists have adopted a productive philosophy of admitting mistakes, apologizing for them (when appropriate), learning from them, and then moving on (show self-compassion). “People can learn to see mistakes not as terrible personal failings to be denied or justified, but as inevitable aspects of life that help us grow” (Tavris & Aronson, 2007, p. 235).
Medical residents who are fatigued make more errors as their fatigue increases (Harvard Work Group, 2004). Similarly, we are less able to focus on our professional obligations and we can become more prone to errors when we are fatigued. Highly competent psychologists engage in positive self-care activities, such as regular exercise, good sleep hygiene, healthy eating, and other activities that promote health and wellness. Part of self-care means accepting our limitations in terms of time, energy, and resources. Healthy psychologists acknowledge that they cannot help everyone and cannot master every facet in the psychology domain.
Some practices, agencies, or organizations may not value ethical behavior, even though they may have an ethics policy, an ethics code, mandatory ethics education, or other formal structures designed to promote ethics. However, the “hidden culture” of the organization often has more influence then formal guidelines when framing ethical dilemmas and determining ethical behavior. “Formal systems are the weakest link in an organization’s ethical infrastructure” (Bazerman & Tenbrunsel, 2011, p. 118). That is, the interactions and comments that occur among members of the organization create the day-to-day ethical tone of an organization. The informal ethical culture of an organization courses through the stories that employees tell, the euphemisms that they use to describe issues, or the socialization rituals that employees undergo. In many cases, the cultural influences on practitioners remain unseen, especially to those who remain frame-dependent.
 Here are some strategies, activities, or routines that some psychologists have used to reduce the gap between good intentions and good behavior.

Self-Directed Activities to Enhance Ethical Practice

Encourage self-reflection (to reduce or to avoid professional narcissism)

Keep a journal or a diary to focus on therapy and possible ethical issues in daily practice, engage in therapy, try to be more open-minded, listen to feelings.
Routinely ask patients for feedback at the end of each session (what did I do that was helpful today? Not helpful?). Routinely gather outcome data. Re-read therapy notes to become aware of any unproductive emotions or countertransference.
Think in terms of ethical issues when facing clinical problems.
            Have a productive philosophy concerning mistakes: Admit them, apologize (if helpful), learn from them, and move on (show self-compassion).
Attend to environmental influences

Encourage friends or colleagues to tell me when they think I am doing something wrong.
Develop schedules – although not too rigidly—and think about time management.
Attend to environmental circumstances that might influence me to engage in less than optimal ethical behavior.
Be aware of temptations to minimize the worth or individuality of clients or other people (e.g., interpret troublesome behaviors as barriers, not manifestations of evil).

Establish Healthy Routines

Make checklists or schedule healthy activities.
Make learning a habit. Attend CE programs (especially programs on ethics), read journals, get advanced training or certification in an area of psychology.
Keep the APA Ethics Code or the Pennsylvania licensing law and regulations close by.
Get in the habit of using an ethical decision-making model.
Belong to and participate in a professional association  (or present at a CE program, join a listserv, start a blog, or participate in student groups, committees).
Uphold ideals without being sanctimonious.
Prevent problems ahead of time

Practice self-care: e.g., pay attention to exercise, sleep hygiene, and diet.
Maintain a good work-life balance.
Reduce dysfunctional emotions through meditation, mindfulness exercises, therapy, or recreational activities unrelated to school or work.
Manage time and tasks carefully (breaking big tasks into smaller ones).
Accept my limitations in terms of time, energy, and resources. (I can’t help
            everyone; I can’t do everything). Balance compassion and altruism with my own needs.[1]
Show concern for others, including your fellow psychologists (help them out if
            I can); commit random acts of kindness; express appreciation (say “thank you”).

Bazerman, M., & Tenbrunsel, A. (2011). Blind spots. Princeton, NJ: Princeton University Press.
Davis, D., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. Journal of the American Medical Association, 296, 1137-1139.
Harvard Work Hours Health and Safety Group. (2004). New England Journal of Medicine, 351, 1838-1848.
Ross, W. D. (1998). What makes right act right? In J. Rachaels (Ed.). Ethical theory (pp. 265-285). New York: Oxford University Press. (Original work published 1930).
Tavris, C., & Aronson, E. (2007). Mistakes were made. Orlando, FL: Harcourt.
Tjeltveit, A., & Gottlieb, M. (2010). Avoiding the road to ethical disaster: Overcoming vulnerabilities and developing resilience. Psychotherapy: Theory, Research, Practice, Training, 47, 98-110.
Younggren, J. (2007). Competence as a process of self-appraisal. Professional Psychology: Research and Practice, 38, 515-516.

[1] W.D. Ross (1998) says that supererogatory obligations should not distract us from our primary obligations to family, close friends, and ourselves.