By Michael F. O’Connor, Ph.D., with the assistance of the members of the APA Board of Professional Affairs Advisory Committee on Colleague Assistance.
One of the most difficult challenges a psychologist can face is how to proceed when a colleague appears to be impaired and/or is acting in an unethical manner. Pope (1994) reported that receiving evidence of a colleague's sexual involvement with a client, for example, was one of the most stressful professional events for psychologists.
Concern about harm to clients or students, for whom and about whom psychologists often care deeply, can be very disturbing.
Personal failings are not often discussed in professional forums, fostering the myth that people who are impaired are a different breed of psychologist, and fostering denial about the real risks and occupational hazards, for the professional, even the colleague we had lunch with last week.
In the therapy room, a psychologist's personal concerns or problems are actively suppressed in order to effectively focus on the needs of the client. This ethic of "other's welfare first" is fundamental to the passionate drive of many psychologists to do good in the world — in part by being personally above reproach. Impairment in a colleague is therefore threatening at a personal level, and may cast the concerned psychologist into an uncomfortable and unfamiliar role.
Professional activities often entail playing the role of social observer and commentator, whether as an academic or practitioner — someone outside the fray and therefore capable of assistance — intellectual or emotional — to others. Evidence that psychologists are all too human can feel personally threatening.
Psychologists tend to value independence of thought and action, making atypical versus inappropriate behavior more difficult to discern in many cases. A desire to see the best in people, and to give others the benefit of the doubt, can also be problematic.
Excellence is a prominent goal in all aspects of a psychologist's work, and it is the expectation of the consumer, as well. Consequently, impairment may be hard to accept for the psychologist or concerned colleague.
In many instances, psychologists are constrained from acting as a result of regulations protecting the confidentiality of those who use their services.
Psychologists may be concerned about how impairment reflects on the profession to which they belong.
Psychologists often work in isolation, or without direct supervision, making determination of ethical violations difficult.
The concerned psychologist colleague also may fear being misunderstood, maligned or retaliated against in some way. There are potential professional and legal risks, and the risk that the impaired colleague may act irrationally or attempt to disrupt the psychologist's practice, for example.
There may be concern about the most effective way to approach the colleague.
These and other factors may result in an avoidance of action, whether intentional or by default. Professionally, this lack of action is not acceptable. Pragmatically, it is not smart. Psychologists can and do harm those they serve at times, and preventing or halting such behavior quickly can be extremely important.
Psychologists bear an ethical responsibility to intervene when a fellow psychologist is thought to be impaired. Impairment, in this context, refers to "…impairment of ability to practice according to acceptable and prevailing standards of care" (Ohio Administrative Code.) Impairment therefore refers to circumstances where professional ability is compromised, and may negatively impact the delivery of professional services by the psychologist.
Impairment, while heightening the risk for ethical violations, does not infer such violations. Nonetheless, psychologists are also responsible to ensure that they are competent to provide the services they offer. Impairment, as defined here, compromises the functioning of the psychologist, and should therefore imply a need for close scrutiny of job-related performance in order to preempt ethical violations. The following sections of the American Psychological Association Ethical Principles of Psychologists and Code of Conduct (APA ethics code draft, October 21, 2001) pertain to this circumstance:
Section 2.01 of the code, "Boundaries of Competence" requires psychologists to practice within the limits of their competence.
Section 2.06a of the code, "Personal Problems and Conflicts" states:
a) "Psychologists refrain from undertaking an activity 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."
b) "When psychologists become aware of personal problems that may interfere with their performing work-related activities adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend or terminate their work-related duties."
Section 1.04 of the code, "Informal Resolution of Ethical Violations," states:
"When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved.
Section 1.05 of the code, "Reporting Ethical Violations," states:
"If the apparent ethical violation has substantially harmed or is likely to harm a person or organization and is not appropriate to informal resolution under Standard 1.04 or is not resolved properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question. "
These ethical guidelines are clear in requiring that action be taken by the impaired psychologist and/or by their colleagues in a situation where ethical violations are thought to have occurred. Decisions about the manner of action are largely left to the psychologist to determine. Determination of whether or not an ethical violation is "appropriate" for "informal resolution", for example, is the psychologist's responsibility. Likewise, whether or not an ethical violation is "resolved properly" is also to be determined by the psychologist colleague. These circumstances will require a judgment call. A focus on the suspected professional's behavior, as opposed to attitude or rumors, for example, will therefore be more useful. Because such decisions may have serious consequences, consultation with peers or experts in practice, ethics or the law will often be wise. These options are further discussed below.
VandenBos and Duthie (1986) have outlined a six-step process for confronting and supporting distressed colleagues. Their work is reviewed and augmented below.
1) Evaluate the information
This step involves collecting and evaluating information related to the colleague's behaviors of concern. The authors suggest making a list of "behaviors and events" that are of concern, as well as the meaning of these occurrences to you. They also suggest that observed occurrences are more persuasive in discussion, than are reports by third parties. Further, you may desire or need more information, which could entail conversations with other colleagues, or consultation with "experts" in the profession to determine the seriousness and correct course of action in the circumstances.
2) Decide who should confront the individual
This step is designed to ensure the appropriate level of intervention with the impaired colleague. The authors note that those closest to the individual may be the most effective, but there are situations — where there is already conflict, for example — that would make a third party more likely to succeed. The option of a group intervention is offered, perhaps more useful in cases where the individual in question is highly resistant or in denial. In circumstances where professional services to the public are seriously impacted, a supervisor may be the most appropriate to intervene.
The authors also note that in situations where there is an imbalance of power, particularly where the impaired colleague is a supervisor or boss, precautions should be taken. They argue that in this case, the concerned psychologist should approach an individual who is equal in power to the colleague. Because a supervisee is inherently vulnerable to a negative reaction from their supervisor, this kind of intervention should be avoided. A supervisor, on the other hand, may engender more defensiveness on the part of the impaired professional, and approach by a peer may be less threatening, in some cases. Nonetheless, supervisors do have ethical and in some cases legal responsibilities in these situations, that should not be ignored.
3) Prepare before the meeting
Here, the authors advise concerned colleagues to organize themselves before approaching an impaired colleague. Making a list of the two to three issues of greatest concern, looking for patterns in behavior that can be identified, and dealing ahead of time with one's own emotions towards the colleague and the task, will be helpful. Again, consultation with peers or experts may be a good idea. It is important to be prepared to acknowledge any biases one might have, as otherwise they may be used by the colleague to deny the validity of your claims.
The authors further advise that the inherent "dual role" in the situation — being both a colleague and an interventionist (authority) — be anticipated and acknowledged, in that one will need to pursue other alternatives if an informal resolution to this problem cannot be found. This kind of informed consent also underlines the seriousness of the circumstances.
One should attempt to evaluate the social aspects of the circumstances as well. If a man is approaching a woman, or a minority group member is approaching a supervisor, negative biases or motivations may be suspected by either party, whether or not they occur. The psychologist who will intervene would do well to anticipate these kinds of problems so that they can be addressed openly, and will not distract from the matter at hand.
4) Consider how you will approach your colleague
The authors advise that one use simple sentences and "stick to specifics" when first broaching the topic with an impaired colleague. Describe the evidence and why it is important. Empathy and compassion is essential but must be balanced with clarity and facts. Acknowledging the difficulty of the conversation and the likely feelings of the colleague will be useful, as will an expressed expectation that the colleague will surely want to correct these problems. Naturally, a judgmental or patronizing attitude will be unhelpful.
5) Speak, listen and discuss
Once the case is made, the psychologist should be prepared to listen compassionately and to consider any additional evidence the colleague may present.
The authors advise that one should be prepared to admit that you may be in error, but you should also ask for explanations of discrepancies or evasions. Acknowledging the likely discomfort of the colleague will be helpful, as will reminding him or her that you wish to help.
Many of the skills of a good therapist will be useful in this phase, but it is important to remember that you are not acting in the role of a therapist. One must attempt to maintain a focus on the concerns presented, and to lead the discussion to a course of ameliorative action. In this way, the intervention may feel and proceed more like a crisis intervention, with abbreviated goals and objectives, identification of resources, and a resulting plan. The authors suggest that one summarize the options and action plan, and make a date for follow-up. Again, it is important for the individual to understand that you will take further action, if an informal resolution plan is not enacted.
6) Follow-up
Here, the authors suggest that one document the meeting and any agreement reached with the impaired colleague, at least briefly. These notes will provide future reference for contact with the colleague, and in the event that the colleague's behavior deteriorates further, will provide documentation for contact with an ethics board or other authority. One should also be clear about the timing of a scheduled follow-up meeting. That meeting, like the initial intervention, should focus on specifics. It is important that goals and objectives in the plan be discussed directly, and that while remaining empathically flexible, one does not avoid setting limits, if errant behaviors have not been corrected.
Confidentiality
The APA Ethical Principles of Psychologists and Code of Conduct requires that confidentiality rights be observed in proceeding with a complaint with or against a psychologist. Confidentiality rights prevent a psychologist from sharing information, gained in a confidential setting, with others — including colleagues, licensing boards and ethics committees, and even the police in many circumstances. So information received in a client psychotherapy session, or in a confidential session with a supervisee, for example, may not be shared without the source's expressed consent. Informed consent rules in this case are also likely to apply, meaning that the source must be apprised of risks associated with disclosure of this information to a third party. A client, for example, should be notified of the likely consequences of proceeding with a complaint against a psychologist. In many instances, the client will be the only one allowed to file such a complaint, if it pertains to actions that they have witnessed or experienced, as complaints from third parties will often not be accepted by governing boards. It should be noted that states vary in their reporting requirements, and that other regulations may supercede the rule of confidentiality, such as child and elder abuse reporting, or Tarasoff requirements, for example. It is important for the psychologist to become familiar with the applicable regulations in the state where they work.
Risk
It is obvious that certain circumstances may be too risky to allow. Such conditions as abuse of clients, criminal behavior or suicidality may preclude a stepwise progression of intervention, as outlined above. These circumstances constitute an inappropriate context for informal resolution, and more direct and immediate action should be taken, in some cases by the authorities. As with psychotherapy clients, it may be important in some instances to act to protect safety first, and ask questions later. Individuals who are impaired, in particular by substances or mental illness, are at heightened risk for suicide. It should be also be noted that male psychologists were reported by OSHA to have the highest rate of suicide for any profession (Ukens, 1995). The moment of intervention may be one of the most painful for a professional who is in trouble. It is important to be aware that this individual may therefore be at significant risk for harm to self or others.
The psychologist colleague is at potential risk for intervening, as well. A colleague who is emotionally or behaviorally unstable may present risk of violence, retaliation or other threat. They may act to negatively impact one's reputation or practice. They may also choose to sue. These risks should not be ignored, but they do not preclude a psychologist's ethical responsibilities. Such circumstances should be carefully evaluated. It may be more appropriate to advocate a family intervention, to hold a group intervention or to call for intervention by the authorities, in some cases. Again, consultation may be helpful in determining the best course of action.
Consultation
It should be clear by now that consultation — with peers, supervisors and/or experts — is invaluable in the process of intervening with an impaired colleague. Consultation refers both to trusted colleagues, and to local or national experts in the circumstances of concern. Ethics consultation can occur at the local level through the local county psychological association, or at the state level through one's state psychological association. Ethics committees and psychology boards will often provide anonymous consultation, meaning that the impaired individual need not be named. These bodies can provide useful information on ethical and legal questions, and in some cases a perspective on the likely trend in a particular situation.
Consultation can provide a sounding board for one's concerns, can offer help with the interpretation of behaviors, and can provide support for strategizing and for the task of intervention. Rehashing an intervention with appropriate others can help discharge any residual tension and reassure that one has acted reasonably. It can also point out mistakes and provide corrective direction. Psychologists may tend toward the independent, but collegial support is good for everyone, not just the impaired. Those who intervene should be careful to manage the information they gather judiciously however, so that the colleague does not become the object of gossip in the professional community.
Power and Politics
As VandenBos and Duthie have noted, power differentials can impact both the likely success and ramifications of an intervention. In highly power-discrepant or complicated situations, these considerations may be very important. It is not reasonable to expect a student to confront a dissertation chair, a new hire to confront a supervisor, or a confused client to confront a venerable therapist. The least powerful in these "onedown" relationships are unlikely to be successful in an intervention, and run significant risk of political, professional or personal harm (VandenBos and Duthie, 1986). Likewise, being in a position of power may engender suspicion and defensiveness on the part of the impaired psychologist. In some cases, it may be preferable to initiate discussion of concerns with an impaired psychologist through a peer-level colleague, or a nonsupervising staff member. The political climate and interpersonal relations among these individuals should be carefully assessed, to the extent possible. Peers who have a history of competitiveness with each other, or those with a simmering conflict, are obviously not good candidates to direct a successful intervention. When Intervention Succeeds If the colleague in question accepts the proposal that they are not functioning adequately, it is important that they be supported in the process of correcting the problem. This may or may not fall to the psychologist who has brought the problem to their attention. In addition to an action plan, this individual will likely need or benefit from additional interventions via supervision, psychotherapy, group work, education and so on. It may be appropriate for the individual to cut back or take a break from work for a time. It makes sense for this plan to be established conjointly with a colleague, supervisor, therapist or other who can help the individual to cover all necessary bases. Isolation and denial can continue to be a problem otherwise. A focus on maintaining or establishing regular, supportive contact with others, a balanced life and a plan for specific problems should be enacted. Established self-care strategies can be very helpful (see below).
Psychotherapy
The need for psychotherapy is indicated when an individual is unable to evaluate or correct their functioning through self-care. The benefit of support during such efforts is crucial, and a characteristic of most therapies. Evidence suggests that psychologists prefer psychodynamic therapy for personal work, perhaps because techniques are not as valuable personally as is a strong and supportive alliance in the therapy.
When intervention fails
If the impaired psychologist is not moved to appropriate action following an intervention, there is the option to try again with a different strategy. One can also move up the chain of command for advisement or control as necessary. It is important that the issue not be dropped, however. The best time to intervene with the impaired psychologist is before harm is done. As noted previously, if efforts to encourage change in the impaired professional fail, it may be time to move to more formal means, such as contacting the local ethics committee or state board of psychology. One should be aware that ethics committees may be more supportive of the impaired psychologist than a psychology board. The psychology boards' primary role is to protect the public, and they may be less concerned with the welfare of the impaired psychologist. Nonetheless, egregious ethical failures and potentially dangerous conditions should be addressed to the appropriate authorities quickly in such cases, before more harm occurs.
Prevention
Strategies that prevent the onset of impairment, when effective, are clearly preferable to intervention after the fact. Self-care strategies have been proposed that seek to ensure resilience in the face of the occupational and personal life hazards all psychologists face to a greater or lesser degree. Psychologists should understand that all psychologists may be vulnerable to impairment in the right circumstance. This is not a problem that affects only a limited group of sub-par professionals. There is also evidence that the profession of psychology may inadvertently select for people who are prone to certain kinds of risk (O'Connor, 2001).
Self-care
The APA Board of Professional Affairs Advisory Committee on Colleague Assistance (ACCA) has established the following recommendations for appropriate self-care:
Take the risks of occupational stress seriously. If you don't know about them, become informed. Honestly assess your emotional, psychological and spiritual health on a regular basis.
Take care of your physical, mental and spiritual health.
Make and maintain professional connections that include the opportunity to discuss the specific nature and stressors of your work.
Seek consultation when professionally or personally challenged, as necessary.
Understand the risks of vicarious traumatization and how to counter them
Pay attention to the need for balance in work, rest and play. Make self-care a priority.
Pursue opportunities for intellectual stimulation in and outside of the profession.
Develop realistic and reasonable expectations about work-load and your capabilities at any given time.
Identify sources of support and use them.
Take regular vacations.
Avoid isolation.
Monitor your use of substances or processes used to relax or for entertainment carefully.
The profession of psychology can be an immensely satisfying one, but it is not without it's hazards. Psychologists in many settings become role-models, and in practice utilize themselves as therapeutic instruments. This very personal role is unlike that of any other profession, in that a person's "self" is so intimately involved in the work. This instrument must be well-tuned and maintained to ensure the best possible services to the public, and a long and prosperous career for the professional.
American Psychological Association (1992). Ethical Principles and Code of Conduct.
O'Connor, M.F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology: Research and Practice, 32 (4), 345-350.
Ohio Administrative Code, 13 && 4731-15 & 4731-16 (Banks and Baldwin, 1993).
Pope, K.S. (1994, August). What therapists don't talk about and why. Paper presented at the Division 12 award ceremony for "Distinguished Professional Contribution to Clinical Psychology" award, annual convention of the American Psychological Association, Los Angeles.
Ukens, C. (1995). The tragic truth. Drug Topics, 139, 66-74.
VandenBos, G.R. and Duthie, R.F. (1986). Confronting and supporting colleagues in distress. Professionals in Distress, Washington, DC: American Psychological Association, 211-232.