Ch 5. Competence in Psychology: Ethical Principles, Practice, and Self-Care
Competence in Psychology
Definition and Importance:
Competence is based on ethical principles of beneficence (to benefit) and nonmaleficence (to avoid harming).
Psychologists must also adhere to principles like respect for patient autonomy, justice, and integrity.
Many definitions highlight the integration of knowledge, attitudes, and skills (e.g., W. B. Johnson et al., 2012).
Epstein and Hundert (2002) definition: "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served" (p. 226).
The authors add cultural competence to this definition.
Lack of competence can lead to disciplinary action from malpractice courts, APA Ethics Committee, state ethics committees, or state licensing boards.
Allegations of incompetence are more frequent in forensic services due to greater scrutiny and disgruntled clients.
Best way to avoid discipline: Aim for the highest standard by upgrading knowledge, practicing and honing skills, and approaching work with humility.
APA Ethics Code Standards Related to Competence:
Standard 2.01a (Boundaries of Competence): Psychologists provide services, teach, and research only within the boundaries of their competence, based on education, training, supervised experience, consultation, study, or professional experience.
Standard 2.04 (Bases for Scientific and Professional Judgments): Requires psychologists to base their work on the knowledge foundation of psychology.
Standard 3.04 (Avoiding Harm): Psychologists take reasonable steps to avoid and minimize harm to clients/patients, students, supervisees, research participants, organizational clients, and others.
Determining Competence:
Proficiency in an area is achieved through external feedback (e.g., faculty/supervisor evaluations in training programs, peer evaluation for experienced psychologists).
Healthy self-doubt is crucial for benefiting from external feedback, as stated by Nissen-Lie et al. (2017): "love yourself as a person, doubt yourself as a therapist" (p. 48).
Psychologists, like others, have blind spots and may overestimate their abilities, necessitating external feedback.
Cognitive biases that external feedback helps protect against include:
Confirmation bias.
Fundamental attribution error.
Illusory optimism (W. B. Johnson et al., 2012).
Dunning-Kruger effect: People overestimate their positive qualities or abilities.
Example (Epley & Dunning, 2006): People overestimated charitable giving or timely task completion.
Example (Walfish et al., 2012): In a sample of 129 mental health professionals, 25\% placed themselves in the top 10\% competence, none in the bottom 50\%; mean ranking was 80^{\text{th}} percentile, modal was 75^{\text{th}} percentile. They believed only 3.6\% of patients deteriorated, lower than the 5\% to 10\% reported by Castonguay et al. (2010).
Competence in Teaching and Research:
Teaching psychologists: Develop competence through courses, supervised experiences, and doctoral program feedback.
If teaching outside optimal academic preparation (e.g., due to vacancies), they should master the subject matter, possibly through consultation.
Need good pedagogical skills, though many learn independently due to lack of departmental support (Komarraju & Handelsman, 2012).
Research psychologists: Obtain proficiency through doctoral programs (course grades, research oversight).
Post-graduation, responsibility rests with the individual, IRBs, funding agencies, and feedback from fellow researchers/peer reviewers.
Ensuring Continued Competence:
Psychology's knowledge base changes, requiring psychologists to stay current and evolve skills.
Half-life of psychology knowledge: Estimated by Neimeyer et al. (2014) as 9 years, projected to be 7 years in the future.
Past training is insufficient without ongoing readings, study, experience, or workshops.
Continuing Education (CE): Required by all state boards for licensure renewal; most psychologists report CE improves competence (Neimeyer et al., 2010).
Longer programs with varied instruction methods are most effective (Buttars et al., 2021).
More group CE linked to fewer patient complaints in physicians (Wenghofer et al., 2015).
Maintenance of Certification (MOC): A movement in medicine for time-limited board certification requiring reevaluation.
Has problems (e.g., lack of exams for highly specialized practices, Irons & Nora, 2015) but preliminary data suggest improved quality (Price et al., 2018).
American Board of Professional Psychology has a similar process for psychologists board certified after January 1, 2015.
ASPPB (2021) is exploring this, though major changes are years away.
Competence Constellation (W. B. Johnson et al., 2012): A "network or consortium of individual colleagues, consultation groups, supervisors, and professional association involvements that is deliberately constructed to ensure ongoing multisource enhancement and assessment of competence" (p. 566).
Examples: consultation groups (as-needed or ongoing peer groups), supervision, mentorship.
Case Example (Journal Club): Five solo practitioners met monthly to discuss articles, share difficult cases, and reflect on practice, leading to better performance and preventing mistakes.
Qualities of Highly Effective Psychotherapists: Strong interpersonal skills, ability to form productive alliances, engagement in deliberate practice (conscious activities to improve competence), and healthy self-doubt to solicit feedback (Wampold et al., 2017).
Sources of feedback: peer discussions, case presentations, patient feedback (standardized interviews, routine monitoring).
Supervision and Consultation:
APA Ethics Code Standard 2.05 (Delegation of Work to Others): Requires psychologists to ensure supervisees/assistants have abilities and perform competently.
Supervisory Relationship: Hierarchical; supervisees lack independent authority on patient care or professional responsibilities.
Applies to all employees, licensed or unlicensed (e.g., trainees, administrative staff, interpreters).
Some state boards require supervision courses.
Case Example (Misunderstanding Supervision): A social worker wanted a psychologist to sign insurance forms while retaining independent practice, demonstrating a misunderstanding of supervision.
Distinction: In supervision, the supervisor retains all responsibility. In consultation, the consultee retains responsibility for the final work product.
Telehealth (Telepsychology):
"Provision of psychological services using telecommunication technologies" (Joint Task Force, 2013, p. 792).
Includes texting, phone, email, but mostly video conferencing (e.g., Zoom).
Infrequent before COVID-19, now common for psychotherapy and assessment.
Meta-analysis (Batastini et al., 2021) found video-conferenced psychotherapy outcomes roughly equivalent to face-to-face.
Opportunities: Serves those with mobility problems, in remote areas, patients who move, or those with highly specialized needs.
Ethical Obligations: All apply to telehealth (competence, boundaries, informed consent).
Specific Telehealth Competencies (APA's Guidelines for the Practice of Telepsychology, 2013):
Technological skill and equipment.
Security of platforms, HIPAA compliance, and other laws.
Ensuring patients can use technology and have private locations.
Informing patients of limitations (e.g., confidentiality breach risk, billing issues).
Having backup communication methods.
Knowing interjurisdictional issues (health care occurs where the patient is located).
Psychologists need licensure or permission in the patient's state.
Many states allow temporary practice for out-of-state licensees.
PSYPACT (Psychology Interjurisdictional Compact): An interstate agreement allowing psychologists with special certificates to practice telehealth/temporary face-to-face in participating states (34 states at time of writing).
Psychologists must follow the patient's state laws (e.g., child abuse reporting, duty to warn/protect).
Scenarios for Telehealth (assuming legal authorization):
Regular, established patients needing services between face-to-face sessions (lowest risk): Ensure patient comfort with technology and understanding of unique telehealth aspects.
Ongoing patients moving to a new location: Continue treatment if the psychologist knows the patient well enough to determine clinical indication.
Complex needs (e.g., suicidal/homicidal risk) may benefit from a local professional with access to local resources.
Psychologist might limit sessions to facilitate transition to a new provider.
New patients through telehealth (higher legal risk): May reveal serious problems requiring emergency/local services (psychiatric referral, day treatment, hospitalization).
Psychologists may lack knowledge of local resources, causing delays.
Precautions: Review previous records, identify local backup agencies/physicians.
Burden on psychologist to prove reasonable measures were taken if substandard treatment is alleged.
Electronic Communications (Emails/Texts):
Must conform to state/federal laws (Chapter 8 discusses confidentiality).
Discuss policies with patients (appropriateness, response times).
Establish policy against immediate response to emergencies.
Limit to routine scheduling or periodic check-ins.
Document clinically meaningful contacts in notes or by storing copies.
Competence with Diverse Patients:
Effective psychologists consider unique needs of each patient.
APA Ethics Code Standard 2.01b (Boundaries of Competence): Requires competence, referral, or supervision when special knowledge is essential for effective services or research.
Includes knowledge of age, gender, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status.
Hays (2009) ADDRESSING acronym: Age/generational, developmental disabilities, disabilities acquired later in life, religion and spiritual orientation, ethnic and racial identity, socioeconomic status (SES), sexual orientation, Indigenous heritage, national origin, and gender.
Authors add citizenship or immigration status.
If lacking proficiency: "obtain the training, experience, consultation, or supervision necessary . . . or make appropriate referrals" (Standard 2.01b).
Exceptions: Emergencies (Standard 2.02) or when services are not otherwise available (Standard 2.01d).
Overarching Principles: Beneficence, nonmaleficence (requiring competence), and justice (procedural for fair treatment, distributive for equal access).
Psychologists should ensure positive, welcoming treatment experiences for all identities to address health care disparities caused by underutilization by marginalized individuals.
Beyond Minimum Standards: Encourage following APA's (2017b) Multicultural Guidelines, Guidelines on Race and Ethnicity in Psychology (2019), Guidelines for Psychological Practices With Sexual Minority Persons (2021), Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (2015b), and other APA guidelines.
Goal: Not just to avoid discipline, but to ensure diverse patients benefit.
Competence With Racial, Cultural, or Ethnic Groups:
Few psychologists hold conscious bigotry, but all may have implicit prejudices inadvertently distancing them from patients.
Psychologists' own socialization may influence assumptions (e.g., pediatric psychologist imposing cultural expectations about marriage).
Cultural humility: "the life-long commitment to learning and refining the skills of responsiveness, engaging in self-reflection, and challenging one’s own assumptions about other races and ethnicities" (APA Task Force on Race and Ethnicity Guidelines in Psychology, 2019, p. 17).
Involves curiosity about clients' lives/cultures/worldviews and willingness to examine one's own implicit biases.
Discomfort with multicultural approaches for some European Americans:
May stem from racial ignorance ("general lack of knowledge about how race shapes experiences") or viewing color blindness as a virtue.
Assumption that acknowledging implicit prejudices/unearned advantages stigmatizes or diminishes worth.
Zero-sum approach (Wright, 2000): Belief that advancement of marginalized groups necessarily diminishes their own status/income/well-being (Rasmussen et al., 2022).
Nonzero-sum approach: Interests can overlap; greater diversity benefits everyone (e.g., more women physicians).
Multicultural perspective can uplift psychologists by fostering closeness with patients/colleagues, increasing competence, and providing useful life skills.
Aligns with intrinsic goals of relatedness, competence, and autonomy (Ryan & Deci, 2008).
Intersectionality: "multiple dimensions of identity and social systems as they interact with each other" (APA, 2017a, p. 166).
Example: Wealthy gay White man advantaged by gender/race/income, but stigmatized by sexual orientation.
Avoid ethnic gloss: Assuming all persons from the same ethnic group are largely similar (Nezu, 2010).
Example: High-income Hispanic American from an old family may differ greatly from recent Central American immigrants lacking Spanish as a primary language.
Ascribed identity vs. self-identity: How others classify a person is not always how they identify themselves (e.g., a Native American hereditary princess with blonde hair/blue eyes).
Defining culture broadly: "belief systems and value orientations that influence customs, norms, practices and social institutions, including psychological processes" (APA, 2017b, p. 165).
Can apply to subgroups (e.g., American military, firearm ownership advocates).
Moving Toward Cultural Competence:
Psychologists need basic therapeutic skills (forming relationships, diagnosing).
More than memorizing facts; it means thinking in cultural terms and focusing on process/content.
Recognize impact of one's own cultural heritage on values/assumptions.
Appreciate generational/life histories, family structure, worldviews, and values of patients.
Culturally adapted interventions: Make treatments compatible with cultural patterns (La Roche, 2021).
Example: American emphasis on individual growth vs. other cultures' emphasis on group/family needs.
Instead of relaxation for self-feeling better, use it for calming to be effective with family members.
American culture views people as basically good and values self-esteem; other cultures may view people as potentially evil, focusing on flaws/moral violations (Stevenson & Haberman, 1998).
Self-esteem promotion may not be congruent with some worldviews.
"Face-saving cultures" (e.g., Korea) may benefit from problem-solving models less focused on internal experiences (Hall et al., 2021).
Understand cultural factors influencing attitudes toward mental health care (normative health-seeking behaviors, attitudes toward professionals).
Affects willingness to seek help, continue treatment, relate to psychologist.
Patients may view psychologists as wise counselors providing specific advice, not for self-exploration.
European American psychologists can be effective with marginalized patients if properly trained.
Honor patient preferences for patient-therapist match: Leads to better outcomes (McAleavey et al., 2019).
Appreciate psychological sequelae of trauma, oppression, prejudice, discrimination, and minority stress for marginalized groups, which explains wariness.
Lack of cultural awareness increases risk of microaggressions: Brief statements or behaviors that convey negative messages, even if unintentional (Example: "You're a credit to your race," implying something wrong with being Black).
Subtle cues like culturally relevant readings, diverse artwork, and diverse staff create an open/safe environment.
Risk of inaccurate diagnosis: Lack of cultural awareness (Schouler-Ocak et al., 2015).
Requires knowing cultural background, including culture-bound syndromes (e.g., amok, Shin-byung, hikikomori, coraje).
Misinterpreting culturally normative behavior (e.g., avoiding eye contact as pathology).
Prioritize self-reflection, redress power imbalances, curiosity about others, and recognize patients as experts on their experiences (APA Task Force, 2019).
Assessment challenges: Failure to use culturally appropriate instruments or adapt traditional ones.
Literal translation may not test equivalent domains (e.g., "shallow brooks are noisy" vs. "Tirar la casa por ventana" in Spanish).
Chapter 10 discusses diversity issues in assessments.
Language proficiency: Ideally, deliver services in preferred language, but often not possible.
Nearly one-fifth of Americans use a non-English language at home; 25 million speak English "less than well" (US Census Bureau, 2021).
Few American psychologists are fluent in other languages.
May need language-proficient psychotherapist or professional interpreter (understand technical issues/rules).
Friends/relatives only as last resort due to conflict of interest/contamination risk.
Explain psychotherapeutic process, confidentiality, boundaries to interpreters.
Debrief with interpreters post-session to minimize problems.
Do not assume bilingual patients use languages interchangeably; language choice can depend on emotional content (Altarriba, 2005).
Competence With LGBTQ+ Persons:
LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Questioning or Queer) are marginalized populations.
Variations in sexual orientation/gender identity are normal (APA Task Force, 2021).
Unique problems and minority stress can exacerbate normal developmental issues (Pachankis, 2014).
Higher risk for physical/sexual assault, family alienation, depression, personality disorders, other mental illnesses than heterosexual individuals.
High suicidal risk in LGBTQ+ adolescents (Wyman-Battalen et al., 2021), reduced with family/social support (Standley & Foster-Fishman, 2021).
Avoid prejudice/discrimination (APA, 2015b; APA Task Force, 2021).
Effectiveness requires straight psychologists to be attuned to their own attitudes, even if implicitly negative, or microaggressions.
Gay-affirmative psychologists: Know issues/stressors, understand emotional reactions, comfortable with explicit sexual issues, understand importance of LGBTQ+ relationships/family definition.
Refer to APA guidelines (APA Task Force, 2021; APA, 2015b).
Case Example (Treatment Goal Misconception): Therapist repeatedly explored patient's mother's feelings about his sexual orientation during grief, distracting from the presenting problem.
Do not assume sexual orientation is the presenting problem for LGBTQ+ patients.
If confusion about sexual orientation is the issue, psychologists should correct misconceptions (e.g., internalized homophobia).
Reorientation/Reparative Therapy: Therapy focused on changing sexual orientation.
Proponents claim successes and right to informed decision consistent with religious beliefs.
Problems: Informed consent is misleading; exaggerates successes, minimizes harms.
No controlled studies attest to effectiveness; many suffer severe harm (Haldeman, 2022).
Reinforces ego-dystonic beliefs, misrepresents sexuality variations as pathology (APA Task Force, 2021).
Psychologists should neither participate in nor promote reorientation therapies.
Competence With Diverse Religious Beliefs:
Religious beliefs profoundly influence thoughts, feelings, behaviors.
Psychologists tend to participate less in organized religion but many are spiritual.
Improve interventions by appreciating religion's role and incorporating patient's beliefs/practices.
Specific competencies needed for religiously committed patients (e.g., Amish, Old Order Mennonites).
Case Example (Mennonite Psychologist with Amish Patients): A Mennonite psychologist helped Amish patients due to her understanding and respect for the Amish Ordnung (rules of living).
Clash of values: Liberal psychologists and religiously conservative patients (e.g., hierarchical marriage, corporal punishment).
Gently guide patients to consider alternatives.
Example: Psychologist listened to resistant parents citing religious doctrines for child-rearing, validated their concerns, and they agreed to return.
Some religiously conservative patients may eye psychologists warily and take longer to trust.
Psychologists should listen carefully and sensitively.
Example: Non-Christian psychologist reassures prospective Christian patients about respecting their values and working within their system.
Shared religion does not mean shared worldview (Knapp et al., 2015). Avoid assuming beliefs.
Inquire about deeply held centers of meaning/religion: Essential for meaningful change (Silberman, 2005; Knapp et al., 2010).
Include a question on intake forms about integrating religious/spiritual perspectives.
Integrating religion/spirituality into psychotherapy:
Examine own biases/blind spots (Plante, 2014).
Have necessary attitudes/knowledge (Vieten & Lukoff, 2022).
Show empathy, know how religion facilitates/harms mental health, have skills to explore mental health implications of beliefs.
Avoid prioritizing a specific religious worldview over patient goals or treatment relationship.
Do not confuse psychologist's role with religious counselor (goal is mental distress, not strengthening faith, improving adherence, or clarifying religious questions).
Require clear understanding and consent from patients.
Skills needed to determine when/how to integrate religion (e.g., prayer/meditation, teaching spiritual concepts, using religious community for support - Pargament, 2007).
Requires knowing psychopathology as well as religion.
Case Example (Psychologist-Priest): A priest/psychologist treated a patient whose "continual praying" was a manifestation of obsessive-compulsive disorder (overscrupulousness).
Competence With Low-Income Patients:
Associated with poor health, preventable illnesses, premature deaths (Chapter 3).
Chronic stressors: Struggle to acquire food, shelter, necessities. One life event can cause cascading losses (job, home).
Childhood adversity from poverty increases risk of asthma, cognitive delays, infections, weakened immune system (Oh et al., 2018).
May live in substandard housing exposed to toxins, without access to parks/grocery stores.
Associated with alienation, pessimism, reduced self-esteem.
May enter treatment with heightened fear of disapproval/disdain.
Consider implicit biases toward lower SES patients (Juntunen et al., 2022).
Avoid being overly critical of unhealthy lifestyle habits (e.g., smoking, junk food).
What appears maladaptive may be adaptive considering totality of lives (Kim & Cardemil, 2012).
Addiction to cigarettes for stress reduction, junk food as affordable/accessible staple.
Poverty increases likelihood of adverse childhood events and high stress (Thompson et al., 2019), including victimization by crime (Woods-Jaeger et al., 2019).
Chronic unemployment/underemployment leads to demoralization, pessimism, shame.
Low-SES patients can develop good relationships and respond well to treatment.
Authors' personal experience working with low-SES patients found emotional rewards.
Require forbearance/patience: More flexibility with no-show policies (transportation, inability to take off work).
Social prescribing (Roland et al., 2020): Refer patients to community agencies for housing, food, safety net resources.
Combine case management services with psychotherapy (Kim & Cardemil, 2012).
Advocate for social policies to mitigate poverty (e.g., food stamps, minimum wage increases) (Chapter 3).
Culture Wars:
Psychologists serve all persons regardless of religious/political beliefs.
Listen carefully, respect autonomy, avoid harm, uphold same professional standards.
Monitor feelings, discuss problematic emotional reactions with colleagues, keep ethical goals in mind.
Example (Firearms): Loaded, unlocked firearms increase suicide risk (Miller et al., 2022).
Some patients resist safety recommendations, suspecting ulterior motives regarding gun removal.
Skillful psychologists understanding firearm culture and treating owners respectfully can overcome obstacles (Hoyt et al., 2021 successful with motivational interviewing for safe storage).
Moving Into New Areas of Competence:
APA Ethics Code Standard 2.01c (Boundaries of Competence): Psychologists planning to provide services/teach/research in new areas must undertake relevant education, training, supervised experience, consultation, or study.
Achieve proficiency credentials (e.g., diplomate in forensic psychology, proficiency certificate).
Prescriptive Authority: Idaho, Illinois, Iowa, Louisiana, and New Mexico allow certain psychologists with advanced psychopharmacology training to prescribe psychotropic medications.
Requirements: Advanced degree, supervised experience, proficiency exam.
Awareness of unique ethical issues in prescribing.
Preliminary data suggest respect from colleagues and fulfillment of goal to serve underserved populations (Peck et al., 2021).
Practice Expansion When No Standards Exist:
No specialty credentials, no uniform sequence of experiences/study/exams.
Knowledge from books/workshops not guaranteed to translate to actual skills.
Example: Child psychologists need appropriate personal style, body language, tone, vocabulary, best acquired through direct contact.
Not competent until another proficient professional has monitored/supervised.
Understand treatment milieu, informal traditions, expectations of new work environment.
Self-assessment: Is knowledge current with scientific literature, have needed clinical skills, appreciate ethical/legal issues (Belar et al., 2001)?
APA guidelines exist for many areas (e.g., older adults, girls/women) to guide study.
Integrated care settings: Psychologists work in primary care/medical settings.
Requires familiarity with roles of other professions, medical terminology, different confidentiality/informed consent rules (Chenneville & Gabbidon, 2020).
Deliver brief, targeted screenings or interventions.
Case Example (Steep Learning Curve): Young psychologist learned to make notes brief and essential in primary care, valuing usefulness to the team.
Emerging or Experimental Treatments:
APA Ethics Code Standard 2.01e (Boundaries of Competence): In emerging areas without recognized standards for training, psychologists take reasonable steps to ensure competence and protect clients from harm.
Questions before using experimental techniques:
Evidence for technique/conditions it benefits?
Greater likelihood of success with other treatments?
Potential harm to patients?
Consulted with peers?
Patients informed of innovative nature?
Monitor patient progress/welfare?
Sufficient training?
Risk of discouraging conventional approaches if experimental treatment fails?
Ineffective treatments are not morally neutral if they discourage more effective ones.
Similar caution for referrals to experimental treatments (e.g., psychedelic-enhanced psychotherapy).
Promising evidence for psychedelic-assisted psychotherapy, but questions remain (long-term effectiveness, comparison to other treatments, effective conditions, optimal psychotherapy integration - Wheeler & Dyer, 2020).
Complementary or Alternative Medicine (CAM):
Complementary: Used with traditional treatments, not regularly taught in professional programs.
Alternative: Used in place of traditional treatments, not regularly taught.
Definition varies by disorder (e.g., relaxation for anxiety is traditional, for personality disorder is CAM).
Definition varies by patient's culture (e.g., curandera for Mexican Americans, massage therapist for non-Hispanic White Americans).
Common CAMs: Herbal teas, vitamins, nutritional supplements, massage therapy, special diets, tai chi, yoga, meditation, Ayurvedic medicine.
CAMs may reflect patient's differing worldview of illness origin (e.g., past life behavior, demons/spirits).
Consultation/coinvolvement with Indigenous healers may help.
Patients use CAMs before or during psychological treatment (e.g., omega-3, St. John's wort, ginkgo biloba for depression; Asher et al., 2017).
80\% of ADHD patients (DeFilippis, 2018), >70\% of Tourette's parents (Patel et al., 2020) use CAMs.
Marijuana/THC: Can be traditional or CAM depending on problem.
FDA approved for certain forms of epilepsy, chemotherapy-induced nausea, AIDS wasting syndrome.
Promising but not front-line for mental health conditions (anxiety, PTSD, autism, Tourette's, chronic pain), research ongoing.
Severe secondary effects for children, pediatricians warn against use (Ammerman et al., 2015).
Caution: Balance benefits with costs (money, time, iatrogenic effects).
Claims of effectiveness often overstated; only 10\% of websites had accurate info on medical benefits (Boatwright & Sperry, 2020).
Complicated by legal prescribed vs. illegal obtained use.
Impact of euphoric effects on treatment unknown when self-medicating (Feingold, 2020).
Anecdotal evidence suggests it can help and be an option when traditional treatments fail (Skelley et al., 2020).
Discuss risks/benefits of CAMs with patients; avoid direct criticism to prevent alienation.
Compromise may be clinically indicated, but do not blindly acquiesce to theories lacking proven efficacy.
Some "natural" remedies are toxic or interact with prescription meds.
Consult patient's physician before commenting on nonprescription meds/herbal remedies.
Electronic Supplements to Traditional Psychotherapy (e-Health/mHealth apps):
Medical devices or mobile apps supplementing telehealth/face-to-face therapy.
Renewed attention due to mental health professional shortage.
FDA approves medical devices but exempts minimal risk devices (Kinney, 2018), common for mental health apps.
Other digital interventions: Wearable devices for real-time physiological data, virtual reality for PTSD (e.g., Vermetten et al., 2020).
Many are proprietary, outcome data not always public.
Apps track symptoms, send self-help reminders.
Decision to use apps depends on patient privacy concerns, comfort with technology, Wi-Fi access, financial resources.
Psychologists must explain procedures, benefits, uses, and safeguard data (Edwards-Stewart et al., 2019).
Many patients use apps comfortably/effectively (Melvin et al., 2019).
Large, growing number of apps (e.g., Martinengo et al., 2019 found 69 for depression/suicide).
Quality varies considerably; some had wrong crisis numbers, lacked prevention steps.
Psychologists must ensure apps meet therapeutic goals.
Exceptions to Competence:
APA Ethics Code Standard 2.01d (Boundaries of Competence): Exceptions for when services are not otherwise available (e.g., rural/underserved areas) or in an emergency.
Nonemergency in underserved areas: Psychologists can deliver services if competent in closely related areas and make reasonable efforts to obtain necessary competence.
Telehealth reduces likelihood of rural psychologists being the only ones available.
Difficult to set fixed rules on stretching competence; utilitarian calculus may be needed (better off with not-yet-competent psychologist or waiting for more qualified?).
Emergencies: Psychologists may provide services to anyone.
Assumed basic relationship-enhancing and diagnostic skills.
Refer patient elsewhere after emergency if needed for ongoing care.
Emotional Competence:
Most psychologists like jobs, feel satisfied, optimistic (Leitzel & Knapp, 2021) due to interactions, intellectual stimulation, sense of accomplishment.
Experience work-related stressors; manage by anticipating and practicing self-care.
APA Ethics Code Standard 2.06 (Personal Problems and Conflicts):
Refrain from activity if personal problems substantially likely to prevent competent work.
Take appropriate measures (consultation, assistance, limiting/suspending/terminating duties) if personal problems limit effectiveness.
Moral principles: Beneficence/nonmaleficence require promoting patient and own welfare.
Practical perspective: Impaired health risks inadequate services.
APA Ethics Code General Principle A (aspirational): Psychologists strive to be aware of physical/mental health's effect on ability to help.
Self-care: "engagement in behaviors that maintain and promote physical and emotional well-being" (Myers et al., 2012, p. 56).
Burnout (Maslach & Jackson, 1981): Emotional exhaustion, depersonalization of patients, lack of personal accomplishment.
Zaki (2020) calls it "repetitive strain injuries of health care professionals."
Essential for psychologists to function well to help others.
Good emotional health: Display interpersonal/facilitative skills.
Burnout: Lack empathy, inability to identify patient emotions (Simionato et al., 2019).
Higher burnout linked to lower quality of care (Salyers et al., 2015).
Low personal accomplishment: Decreased productivity, more absenteeism (Hammond et al., 2018).
Higher therapist burnout scales linked to poorer patient outcomes (Delgadillo et al., 2018).
Resilience/confidence predicted patient improvement (Green et al., 2014); mindfulness/resilience predicted reduced patient depression (Pereira et al., 2017).
Emotional Health Data: Mixed.
Many report burnout, students report high emotional distress (Hobaica et al., 2021; Myers et al., 2012), many students from dysfunctional families (Brems et al., 1995).
Psychological distress among psychotherapists may be no greater than laypersons (Norcross et al., 1986).
Psychologists' Neuroticism scores similar to nonclinical samples (Blume-Marcovici et al., 2013: Psychologists 5.1, nonclinical 4.8).
Chronic Hassles: Paperwork, inadequate time, managed care restrictions.
Continual stress of dealing with emotional pain of others, difficult patients (Rupert et al., 2015).
Compassion fatigue: Inability to feel empathy due to overwork.
Caregiver's dilemma: Empathy facilitates care but can lead to burnout (Zaki, 2020).
Higher risk for those with personal trauma history, many trauma patients, or unclear boundaries (Mailloux, 2014).
Exposure to draining patients should not prevent meeting primary obligations.
Professional Acculturation Model (Chapter 2): Separation strategies (strong personal ethics, weak professional ethics) may increase vulnerability to compassion fatigue compared to integration strategies.
Factors linked to burnout:
Work setting: Agency psychologists report more burnout than independent practitioners (Yang & Hayes, 2020) (less autonomy, greater exposure to difficult behaviors).
Age: Burnout decreases with age (Nissen-Lie et al., 2021; Yang & Hayes, 2020) (better self-care skills, distressed leave profession, older psychologists screen patients).
Social support: Reduces self-reported burnout (Rupert et al., 2015; Yang & Hayes, 2020), consistent with loneliness research (Holt-Lunstad, 2021).
Gender: Mixed results; correlation may be due to higher percentage of early career women psychologists.
LGBTQ+/Psychologists of Color: No studies on burnout rates, but assumed higher stress due to minority stress and early career status.
Personal characteristics: Well-being, self-efficacy, extraversion, emotional coping skills, mindfulness linked to less burnout (Yang & Hayes, 2020).
Schemas:
Trainees: "unrelenting standards schema" (perfectionistic/rigid expectations - Kaeding et al., 2017, p. 1783).
Psychologists: Unrelenting standards and "self-sacrifice schemas" (sacrificing needs, seeking approval, high internalized expectations - Simpson et al., 2019, p. 41).
History of early trauma increases personal burden (Nissen-Lie et al., 2021).
Confronting Professional Stressors:
Patient suicide/attempts: Leitzel and Knapp (2021) found in 2020, 6\% psychologists reported a patient death by suicide, 29\% reported an attempt during treatment.
Triggers sadness, grief, guilt; especially difficult for trainees (Gill, 2012).
Assaults: Rare, usually in inpatient facilities/prisons.
Stalking and Harassment: More common.
Kivisto et al. (2015): 1/4 psychologists harassed, 1/7 stalked, 1/5 threatened.
Stalking behaviors: Unwanted calls/texts/emails, unwanted approaches, being spied on/followed, showing up near home/work (A. J. Kivisto & Kivisto, 2018).
Case Example (Frightening Situation): Psychologist stalked after referral; car vandalized, office window broken, false letter to wife.
Response: Changed routine, installed alarm, notified family, consulted attorney.
Reducing risk: Maintain clear boundaries, address inappropriate behaviors early.
Stalkers stop on their own, few physically attack, but difficult to predict.
Victim response: Seek emotional support, ensure safety (alarms, changing habits), document encounters, seek legal advice (Erickson Cornish et al., 2019).
Loss of Professional Competence (Impairment):
Standard 2.06a: Restricts activities if personal problems prevent competent performance.
State licensing laws make health-related loss of competence (impairment) grounds for disciplinary action.
Psychologists who know/should know they are impaired must withdraw or seek supervision.
Many misdeeds observed in context of personal crisis/severe stress.
Adequate self-care could prevent many ethical violations.
"Impairment" traditionally used, "loss of professional competence" may be better (Elman & Forrest, 2007).
Estimates vary, but many psychologists will experience a mental/physical disability preventing adequate performance.
Authors consulted with psychologists who curtailed work for serious illnesses (e.g., cancer) and returned to full-time practice.
Psychologists who know limitations, seek consultations, adjust caseloads protect themselves/patients and incur little disciplinary risk.
Untreated/inadequately treated mental illnesses, substance misuse, or lack of insight risks patient well-being and disciplinary actions.
Response to mental health treatment: Psychologists respond well.
90\% found psychotherapy helpful, half believed it made them better psychologists (Norcross, 2005).
84\% found it helpful (Bearse et al., 2013).
State/provincial psychological associations offer CE, articles, workshops on reducing distress/preventing competence loss (focus on self-care, profession-specific stressors).
Case Example (Positive Outcome): Psychologist with 2 DUIs entered treatment, supervision, AA, medication, drug monitoring; returned to practice sober and speaks publicly on recovery.
Graduate programs should monitor students for reduced competence signs, help address problems, or remove from program.
Standard 7.04 (Student Disclosure of Personal Information): Permits training programs to require personal disclosures from impaired students.
Flourishing as a Psychologist:
Most psychologists value careers, would choose it again, and flourish.
"To flourish means to live within an optimal range of human functioning, one that connotes goodness, generativity, growth, and resilience" (Fredrickson & Losada, 2005, p. 678).
Flourishing involves high ratio of positive to negative emotions and behaviors contributing to others' welfare.
Maximize positive emotions (love, appreciation, gratitude, joy, curiosity) consistent with professional duties.
Self-care insights: Graduate students with good sleep hygiene, social support, emotion regulation, mindful self-acceptance tend to have good mental health (Myers et al., 2012).
Lifestyle behaviors integrating mindfulness, spirituality, positive psychology enhance personal lives (Wise et al., 2012).
Implementation: Embed oneself in a caring community (W. B. Johnson et al., 2013).
Norcross (2000) urged psychologists to create environments reinforcing behaviors promoting personal/patient welfare.
Environment should provide feedback loop for continual reflection on procedures/outcomes (consultation, study groups, patient outcome data, informal colleague conversations).
Social support: Especially important for confronting the "emotional contact sport" of psychotherapy (Sternlieb, 2011).
Share burdens, involve others in decisions, express dismay to reduce stress.
Share joys to double them.
Regular consultation provides shared clinical expertise, ensures high standard of care ("You have to share it to bear it"; Sternlieb, 2013, p. 21).
Coster and Schwebel (1997) found social support key for "well-functioning" psychologists; Dlugos and Friedlander (2001) found passionately committed psychologists continually sought feedback/supervision.
ASPPB (Association of State and Provincial Psychology Boards, 2021) Footnote:
Association of licensing boards from Canadian provinces/territories and American states/territories/D.C./Puerto Rico.
Develops Examination for the Professional Practice of Psychology (EPPP) and provides resources.
Recommendations non-binding but reflect current thinking of leaders in regulation.