W12 - Implementing Our Ethical Ideals Through Sufficient .
10/18/2017Implementing Ethical Ideals ThroughSufficient HumilityJeff Sternlieb, Ph.D.Lehigh Valley Health NetworkPast‐Chair, PPA Colleague Assistance CommitteeSamuel Knapp, Ed.D. ABPPDirector of Professional AffairsPA Psychological AssociationLearning Goals:At the end of the workshop participants should be ableto identifyCommon factors that limit our ability to addresscomplex clinical and ethical issuesHow sufficient humility and curiosity can led tobetter outcomesHow sufficient humility can help us adhere to thespirit of the APA Ethics CodePPA Ethics and C.E. Conference ‐ October 2017Hidden Ethics CodeWhat’s Behind the Curtain?Ethics Code is more than a random set ofrequirements and prohibitions.Instead, the enforceable standards are linked tooverarching ethical principles.Implementing the spirit and letter of the overarchingethical principles requires commitment on the part ofindividual psychologistsWhat’s Behind the Curtain?Hidden implies Implicit, not ObviousOverarching Ethical Principles NeedDecodingLetter and Spirit Imply Deeper LevelsThe First CurtainUnderstanding the standards in thecode of conduct requiresunderstanding the overarchingethical (General or Aspirational)principles which form thefoundation of the Code.Commitment Requires ActionWhen we open the curtain, it’s up to you1
10/18/2017Overarching Ethical PrinciplesBeneficenceNon‐maleficenceRespect for Patient AutonomyJusticeFidelity to relationshipGeneral (public) beneficenceCompetence“The habitual and judicious use ofcommunication, knowledge, technicalskills, clinical reasoning, emotions,values and reflection in daily practicefor the benefit of the individual andthe community”Epstein and Hundert, 2002Ethical PrinciplesIdeally, the enforceable standardsshould be based on these aspirational(General) and overarching ethicalprinciples.e.g., competence (standard 2.01)–based on beneficenceBeneficenceBeneficence means helpingothers which is often reflected inbeing competentNon‐maleficence is the otherside of beneficence‐ it meansavoiding harming othersCompetence (cont.)habitual (on a daily basis), and alsojudicious (requiring decision making)components include emotions andvalueswith the goal of helpingindividualsand societyEthical Principles (2)Informed consent (3.10 andelsewhere) based on respect forpatient autonomyAvoiding treating patients whenimpaired (2.09) based on non‐maleficence2
10/18/2017Counter Intuitive Statement:The Second Curtain:Ethics Codes do little to improve thebehavior of organizations or peopleAttending lectures on ethics is theleast effective way to encourageethical behaviorThe Second Curtain:What factors will lead us to actuallyimplement the spirit (and letter) ofthese overarching ethical principlesin our daily practices?What personal traits or factors willincrease the likelihood that we canimplement the ethics code?PrideNarcissismHumilityPride:Authentic Pride: Satisfaction in a jobwell done!Hubristic Pride: A desire to dominateor controlNarcissismHigh self‐esteemNarcissism: entitlementnot meritnot to get along, but to get aheadnot intimacy, but controlAssociated with materialism, dishonesty, andreduced sense of empathy3
10/18/2017HumilityHumilityHarmful humility: perception ofoneself as insignificant, unimportant,unworthyMoist or damp conditionsHealthy (sufficient) humility: free fromostentation, modest, more accurateappraisal of one’s self(just kidding!)Applying Sufficient Humility Emotional Intelligence Dan Goleman Johari Window Luft and Ingham Reflective Practices Epstein; and others22Johari Window: Luft and InghamPublicBlindUnknownOTHERKnownJohari and Sufficient HumilitySecretKnownHiddenSELFLess afraid of hiding things fromothersMore willing to look at ourselveswithout fear of being indulging inharmful humility (looking at ourselvesas unimportant or unworthy)Unknown4
10/18/2017Keeping Ourselves HonestSeeking Feedbackfrom colleaguesfrom patientsExperimenting with DisclosureIntrospection, Reflection, Personal ExplorationBetter vs. WorsePoor communication vs. good communicationSocial isolation vs. socially embeddedFatigue vs. self‐care, positive emotionsStagnation vs. conscientiousnessDecay vs. Incremental theoryProfessional narcissism vs. self‐reflectiveBetter v. ationThe Second Curtain (cont.)Overarching Principles:Understanding to Implementatione.g., What do we know about goodand bad treatment?Seldom a knowledge gap alone!Better v. WorseHow do we go about ensuring thatwe are more consistently on the“good” side of the continuum?Better v. Worse (cont.)Self‐awareness: “You have to be it tosee it”Self‐reflection: “You have to name itto tame it”Self‐regulation: “You have to share itto bear it.”5
10/18/2017Definitions:Sufficient Humility and Self‐AwarenessWe do not have to be narcissistic: i.e.,perceive ourselves as dominant or betterthan others.Instead, we are free to see ourselvesaccurately, with flaws and limitations.“In the beginners mind the possibilities aremany, in the expert’s they are few.”Professionalism: “a commitment on the part of theindividual practitioner to self‐monitor andimprove”Meta‐competence: “the ability to assess what oneknows and what one doesn’t know”Reflection: deliberate and objective self‐analysiswith the goal of gaining insights to improve futurebehaviorSuzuki RoshiSelf‐AwarenessHow well do we know our areas of competence?How well do we understand our personalstrengths and weaknesses?How well do we understand how we comeacross to others?Or: Are we “strangers to ourselves?”How Aware Are We? (cont.)Most psychologists think they get better withage (Orlinsky, 1999)BUT:*overall outcomes show small increases withage (Goldberg et al., 2016)*value of clinical judgment increases verylittle (Spengler et al., 2015)*disciplinary actions by licensing board arehigher among older psychologists (Cullari,2007)How Aware Are We? ‐ some Data!25% of therapists rated selves in the top 10%;none in the bottom 50% (Walfish et. al., 2010)Therapists claimed patient deterioration rates thatwere one third to one half the known rate ofpatient deterioration (Walfish et al., 2010)Psychologists often disagree with patients onhelpful or harmful events in treatment(Castonguay et al., 2010)How Aware Are We? ‐ (cont.)Implicit prejudices (“uncomfortableegalitarians”) Banaji and Greenwald, 2013Self‐reported cultural competence shows alow correlation with actual culturalcompetence (Constantine & Ladany, 2000)6
10/18/2017How Aware Are We? ‐ (cont.)Tend to minimize pain of patients who donot like (De Ruddere et al.,2011)Tend to over‐pathologize patients who carryexcess weight (Pascal & Kurpius, 2013)Tend to minimize pain of patients whom weview as attractive (LaChappelle et al., 2014)How Aware Are We? ‐ (cont.)Immediate self‐awareness:What emotions do patients generate inus?Are we sufficiently aware of ourselves toknow which patients will activate ourself‐doubts or fears?Self‐AwarenessHow Aware Are We? ‐ (cont.)The number one reason for physicianmisdiagnosis at a major urban hospital wasconfirmation bias (Lisa Sanders, 2009).Blind spot bias‐ we tend to minimize theextent to which we believe we arevulnerable to biases (Pronin & Kugler,2007)Atul GawandeExcellence– using coaches in health caretakes effortnot always pleasantImpact of Our WorkJournaling feelingsIs it stressful, overwhelming, exhausting?Sharing feelings, reactions, thoughts withothersIs it reflected in:humor we use?labels we give patients?emotional leaks?Keeping work‐life balance (avoiding egodepletion)– “no glucose, no will power”7
10/18/2017Impact of Work (cont.)Nightmare patientTrain wreck“borderline”Patient from hellAccident waiting to happenNot the sharpest knife in the drawer44The Third Curtain ‐ ExcellenceThe Third Curtain ‐ ExcellenceCaution: Personal Reflection Required!Most Intimate and PersonalBuilding Trusting RelationshipsTrust Myths and RealitiesTrust ComponentsCompetenceCharacterExcellenceThink of ourselves not as individualpractitioners, but as a system.“A good idea is a system”– SteveJohnson, scientific historianExcellenceSufficient Humility allows us to be excellent.We can look for authentic pride: satisfaction in ajob well done.We do not have to defend a persona of beingperfectWe can cooperate with othersShare in their joys and accomplishments8
10/18/2017Counterintuitive StatementsConfusing QuestionsDo you want to do good or do you want goodto be done?What do you want the person next to you tolearn today?We do not care what you learntoday, but we care very muchwhat YOU learn today.Resume Building vs. Eulogy Virtues?David Brooks, NY Times, April 2015Self‐ReflectionAn on‐going metacognitive process arising out of acommitment to life‐long professional developmentthat could include both deliberate and tacitprocesses. Its goal is to expand expertise throughattention to and a critical evaluation of one’spersonal experiences, feelings, thoughts, behaviors,fantasies, bodily experiences, and interactions withothers which is integrated with scholarship. It shouldhelp individuals gain new insights that can be appliedto new situations.Self‐Reflection (cont.)We all have a tendency to overestimateourselves and our abilities.A modest amount of overestimation isacceptable, but we need to avoid“professional narcissism”“I am more than my liabilities and less thanmy capabilities.”Parker PalmerSelf‐Reflection (cont.)Reflection on our work and the impact it has onus is the single best thing we can do to improveourselves, and it is the most difficult activity tomake time for and to effectively incorporate inour routines.We can do better at it, when we free ourselvesfrom hubristic prideSelf‐Reflection (cont.)Written or spoken?Alone or in a group?Done routinely or sporadically?Productive or ruminating?9
10/18/2017Increasing Self‐ReflectionSelf‐compassion: love and forgive selfin spite of mistakesMonitor negative self‐talkStructuring self‐reflection activities(e.g., observe tapes with reflectiveprompts; ask questions: “How did Ifeel?” )JournalsBalint groupsBarriers?TimeMoneyTrusting ion Exercise ‐ Part 2Now take those three strengths and indicatehow, under some circumstances, thesestrengths could also be a source of greatvulnerability or weakness.Increasing Self‐ReflectionMindfulness training– shows positive impacton patient outcomes in some preliminarystudiesFeedback– immediate and concreteSelf‐ affirmationLiteratureFirst Self‐Reflection ExerciseTake a couple of minutes and brieflywrite down what you believe your threemost important strengths are as apsychologist.Do not be overly modest (don’t writedown anything that you would not wantto share with others)Second Self‐Reflection ExerciseIdentify a recent event in which you believeyou acted particularly well. What did you dowhich was so effective?Identify a recent event which did not turnout the way you wanted. What could(should) you have done differently?10
10/18/2017Third Self‐Reflection ExerciseThere is a thread you follow. It goes amongthings that change. But it doesn’t change.People wonder about what you are pursuing.You have to explain about the thread.but it is hard for others to see.While you hold it you can’t get lost.Tragedies happen; people get hurtor die; and you suffer and get old.Nothing you do can stop time’s unfolding.You don’t ever let go of the threadThird Exercise (cont.)Take a few minutes and write down:What is the thread in your life?Can others see it?How can you better illuminate your thread?William StaffordFourth Self‐Reflection Exercise“My Future Self”How would you like to be described at yourretirement party? What adjectives wouldyour friends or patients use to describeyou?Prompt list:1. Ask patient about their perception oftreatment and relationship.2. Does the patient feel heard andunderstood?3. Do you and the patient agree/operationalize goals the same?4. Was there confirmatory bias on yourpart?5. Are there any other factors toconsider?Self‐Reflection Option4 session rule:If, after four sessions, a patient has notimproved or the treatment relationship isnot good, for no obvious reason, it is time tosystematically reflect upon treatment.Self‐Regulation:Monitoring our behavior and taking steps toensure we are acting in a manner consistentwith our goals.Mental ‐ intrusions on our thoughts orfeelingsEmotional ‐ take emotional temperaturePhysical ‐ sleep, energy, exerciseSpiritual/values ‐ remind ourselves of ourgoals11
10/18/2017Self‐Regulation (2)Self‐care is a 50/50 propositionWork/life balance ANDMonitoring feelings and reactions to thework itselfunfinished business,second guessing,self doubt, etc.Environmental FactorsWhat aspects of your environment supportyou in reaching your goalssupportive colleagues,trusting relationships,technical support,others?Are you frame vigilant?Self‐Regulation“Some Men Eat Ants”S – awareness of self reactions, feelings, etc.M ‐ awareness of moral foundations, goals,and valuesE ‐ sensitivity to environmental demands orpressuresA ‐ anticipate problemsAnticipate ProblemsUnique factors in your clientpopulation.Unique factors in your work dayUnique personal demands that maydivert your attention, albeittemporarily(More) Counterintuitive StatementsBeing selfish is not always being selfishThank You!Altruism can be unethical12
10/18/2017ReferencesBanaji, M., & Greenwald, A. (2013). Blindspot. NY: Delacorte.Castonguay, L. et al. (2010). Helpful and hindering events inpsychotherapy. Psychotherapy, 47, 327‐344.Constantine, M., & Ladany, N. (2000). Self‐reported counselingcompetence scales. Journal of Counseling Psychology, 47, 155‐164.Covey, Stephen, (2006), The Speed of Trust, The Free Press, NYCullari, S. (2009 June). Analusis of board of psychology disciplinaryactions, PA Board of Psychology Newsletter, 1‐2.DeRuddere, et al., (2011). When you dislike patients, pain is takenless seriously. Pain, 152, 2342‐2357.References (cont.)Goldberg et al., (2016). Do psychotherapists improve with time and experience?Journal of Counseling Psychology, 63, 1‐11.Goleman, Daniel, (1995), Emotional Intelligence, Bantam Books, New YorkLaChapelle, et al., (2014). Attractiveness, diagnostic ambiguity, and disability cuesimpact perceptions of women with pain.Luft, Joseph and Ingham, Harry, (1955), The Johari Window, a graphic model ofinterpersonal awareness". Proceedings of the western training laboratory ingroup development (Los Angeles: University of California, Los Angeles)Rehabilitation Psychology, 59, 162‐170.Orlinksy, et al. (1999). Psychotherapists assessment of their development atdiffrerent career levels. Psychotherapy, 36, 2013‐215.Pronin, E. & Kigler, M. (2007). Valuing thoughts, ignoring behavior.Journal of Experimental Social Psychology, 43, 565‐578.Sanders, L. (2009). Every patient tells a story.Spengler et al.,(2009). The meta‐analysis of clinical judgment. The CounselingPsychologist, 37, 350‐399.13
Johari Window Luft and Ingham Reflective Practices Epstein; and others 22 Johari Window: Luft and Ingham Public Blind Secret Hidden SELF OTHER Known Known Unknown Unknown Johari and Sufficient Humility Less afraid of hiding things from others More willing to look at ourselves without fear of being indulging in
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