The Stress-Distress-Impairment Continuum for Psychologists

by the Advisory Committee on Colleague Assistance

This document is intended to illustrate the likely progression of stress — to distress — to professional impairment for those psychologists who do not pursue or receive appropriate ameliorative efforts that would otherwise interrupt this progression. It is therefore intended as a heuristic, and as an invitation to monitor and carefully manage one's own personal stresses and needs, in order to ensure optimal professional functioning.

Stress

Obviously, everyone experiences stress at various points over the course of their lives. Stressors range from the minor — being late for an appointment, missing an exit on the freeway — to the major — loss of a loved one, serious personal injury or illness. Stress will induce physical, cognitive and emotional changes in the individual to varying degrees, relative to the individual in question and the level of stress.

Psychologists experience the stress of everyday living like anyone else. And, like anyone else, psychologists typically experience stress related to their work, as well.

In addition to these universal stressors, there are specific occupational vulnerabilities common to psychologists. Such occupational vulnerabilities should not surprise us. Most occupations entail certain risks, hence the existence of hardhats, for example. These vulnerabilities are related both to the person and personal history of the psychologist, and to the nature of the work psychologists do.

An interactive model is helpful in understanding how the person and the work of a psychologist may contribute to professional distress and impairment in the profession. Psychologists bring with them to their work both strengths — knowledge, resources, life-experience, sensitivity and training — and weaknesses — historic emotional injuries, a tendency to over-identification, the need to be seen in a positive light, for example. In fact, vulnerabilities related to the person of the therapist tend to parallel their strengths and in many cases stem from the same source. For example, a person who has suffered loss in childhood will likely be more sensitive to such a condition in others, and therefore more able to understand and guide another in those circumstances. But a person who has suffered may also feel suffering more acutely, or be prone to rescuing rather than helping a client find her own way out of the predicament facing her. In other words, what makes us helpful may also make us vulnerable.

Work-related stress, for psychologists, includes that caused by the social context of the work — including the stigma associated with psychotherapy, decreasing financial rewards, limitations on service provision, for example — and those related to the psychologist's role — repeated exposure to emotionally difficult material, the need for careful maintenance of boundaries with the client, the need to control one's emotional response in the therapy room, an isolated work environment, and limited control over outcomes, for example. It is hard enough to hear about the often intense emotional pain of the client, but to also actively repress one's own emotional response, and to have limited ability to ease such pain, can be wearing over time. The responsibility of the psychologist to protect the welfare of the client and the public can also be wearing. Many of these working conditions have been linked to burnout, which is more common in circumstances that fail to satisfy personal needs, where there is role conflict and ambiguity (should I call the police or wait for the client to contact me?); responsibility for people versus things; limited decision making power; and upsetting, frustrating or difficult work (Ackerly, Burnell, Holder and Kurdek, 1988.) There are many other examples of the ways in which the person and role of the psychologist may cause stress that are beyond the scope of our purpose here. These may be further explored by going to ""Occupational Vulnerabilities for Psychologists."

Psychologists have an ethical responsibility to remain resilient in the face of such influences, and to know when they need assistance, or other alternatives, in order to remain resilient. They also have a responsibility to know when they cannot do so. These responsibilities are a tall order, requiring psychologists to acknowledge their personal limitations, in some cases.

The habitual role of helper may make it difficult for psychologists to acknowledge their own need for assistance at times. They may be uncomfortable in the role of the one who is helped, or they may, with the best of intentions, try to 'tough it out' regardless of their own well-being. In these circumstances, the psychologist is likely to become distressed.

Distress

Distress, as discussed here, refers to an experience of intense stress that is unresolved, and therefore distracting and difficult to manage — a psychologist with a chronically suicidal patient, or with a child who is very ill, are examples. It may be surprising to learn that over 59 percent of psychologists have reported working when, in their view, they were too distressed to be effective, (Pope, Tabachnick & Keith-Spiegel, 1987). The distressed psychologist may be ruminative, have obsessive thoughts related to the stress, experience sleep or appetite problems and so on. They may use inappropriate or ineffective means to manage their distress, in which case they are at greater risk for impairment. Distressed individuals are more vulnerable to substance abuse problems, for example, as they search for ways to ameliorate their pain. To the extent these avenues lead to further problems and distress, the individual may become frankly impaired.

Impairment

Impairment here refers to a condition that compromises the psychologist's professional functioning to a degree that may harm the client or render services ineffective — a psychologist who is chronically late or absent for appointments or who has developed a substance abuse problem and provides services while under the influence are examples. Impairment and improper behavior are not synonymous. But impairment implies that the functionality of the professional is compromised. Impairment is a condition for which the individual should certainly seek assistance. The impairment may also impact the awareness of the psychologist however, such that one is unable to recognize the seriousness of one's condition. In this case, the likelihood of inappropriate, unethical or even illegal behavior is great, and the professional is now a potential threat to those who seek her services.

Improper Behavior

The circumstances leading to improper professional behavior have been described in the literature on impairment (Gabbard, 1991). Although much of the early focus was on sexual improprieties with clients, it has been noted that other improper behaviors — dual relationships and fiscal improprieties, for example — may be at least as damaging (Schoener, 1995).

The modal impaired professional has been described as a middle aged man, in the midst of or following a personal crisis such as a divorce, who gradually erodes the boundaries of the therapeutic relationship in an effort to meet personal needs through the client. Variations on this theme are endless, and this circumstance creates an unsafe, therapeutically ineffective, and potentially abusive condition for the client.

Summary

The continuum of stress to improper behavior may be thought of as a "slippery slope." It is not stress or even distress that leads to impairment, but inappropriate or ineffective means of managing stress. Again, stress is a fact of life. For these reasons, the Advisory Committee on Colleague Assistance has focused its efforts on prevention and education, emphasizing self- assessment, effective balancing and self-care strategies, and consultation for practitioners. We cannot eliminate occupational hazards from our work, but we can learn to be effective and resilient in the face of them. (See "Professional Health and Well-being for Psychologists")


Stress-----------Distress------------Impairment---------Improper Behavior

References

Gabbard, G. O. (1991) Psychodynamics of sexual boundary violations. Psychiatric Annals, 21(11), 651-655.

Pope, K. S; Tabachnick, B. G; Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42(11), 993-1006

Schoener, G. R. (1995). Assessment of professionals who have engaged in boundary violations. Psychiatric Annals, 25(2), 95-99.