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Developing a Professional Identity

Posted By Randall Reitz, Friday, May 3, 2013
Developing a Professional Identity

Why do some clinicians excel at integrated care while others flounder?

Why do some of us embrace innovation while others yearn for traditional models?

The development and orientation of one’s professional identity plays a central role in predicting success in integrated care. This 5-week blog series will present professional identity development from numerous perspectives. Following this initial post, each week we will host posts that react to and build upon the previous blog from the perspective of a different discipline:

May 9th—Psychology

May 16th— Graduate student

May 23rd—Family Medicine

May 30th—Pediatrics

 What is Professional Identity?

My interest in this topic was first piqued by the McDaniels et al (2002) curricular article for training primary care psychologists. The authors observe that "Psychologists-in-training need to develop the skills that solidify their identity as psychologists. Psychologists who have a positive professional identity are most likely to be able to work in collaborative primary care settings.”

Intrigued by this comment, I set out to investigate professional identity development. I found precious little in the health education literature, and nothing specific to integrated care. About the closest thing I could find was an article that applies the Chickering Theory of Identity Development to medical residency education. The Chickering Model describes 7 "vectors” through which trainees and students pass during professional development. They are:

1. Developing competency

2. Managing emotions

3. Developing autonomy

4. Establishing identity

5. Developing mature interpersonal relationships

6. Developing purpose

7. Developing integrity

Most theorists apply Chickering’s 4th stage, "Establishing Identity,” to under-graduate education and look at the global self-concept (e.g. cultural identity, appearance, self-worth, social role). However, I would assert that professionals pass through each of Chickering’s vectors at each level of training. The level of stress and the pace of development become more manageable with each new training or employment experience, but the vectors are clearly experienced.

For example, nearly all of us can identify our own experience with the vectors upon entering grad school or medical school. We are finally entering the realm of our chosen vocation and we don’t want to screw it up. Looking back at my experience at Indiana State University, here are the cognitions I recall with each of the Chickering vectors:

Developing competency"I need to learn Excel, SPSS, Powerpoint, email (yes, I’m that old) at the same time I figure out Minuchin, Bowen, White, and de Shazer. I was able to fake my way through undergrad, but this is a whole new level of expectation”.

Managing emotions"I’ve got my supervisor behind the 2-way mirror witnessing a completely out-of-control couple in the middle of a screaming melted down. Chest tightening, palms sweating, thoughts racing, tongue stuttering, just keep it together for the sake of the couple.”

Developing autonomy—"OK, the first day of my off-campus internship site. I’ll have weekly meetings with my on-site supervisor and the program faculty, and I can consult with them by phone if I need. I can be successful here.”

Establishing identity—"I’m a narrative therapist who has been able to help many couples and families. People with a similar skill level as me have gone on to careers in academia, why not me? I love what I’ve read about collaborative care, and working with physicians. People scream less in medical settings.”

Developing mature interpersonal relationships"I’m the only person in my program who fancies collaborative care. How can I bring them along? Which potential mentors could bring me along?

Developing purpose—"For the last 6 months of my masters degree, I haven’t read a single assigned reading, preferring instead to read texts and articles on collaborative care and medical family therapy. I’ve also sought out any case I could find with a connection to physical illness.”

Developing integrity—"I’m confident in my core family therapy skills and in my ethical practice. While my opportunities to collaborate have been limited, I’ve demonstrated professionalism in my accessibility and proactivity.”

Each additional career stop has offered a fresh experience with the vectors, but with the benefit of the competency and connections made with previous steps:

Doctoral program → Internship → Clinic management → Residency faculty

Each of these experiences has broadened my perspective regarding collaboration and has deepened my commitment to our field.

In my supervision and employment of medical and behavioral health providers in integrated settings, I‘ve come to appreciate that these settings are like the Briar Patch from the Uncle Remus stories: either noxious or nonpareil. While some clinicians have a preternatural, innate collaborative ability, others can’t get out of their own way. I believe the key differences come from a professional identity that grew out of personality. Perhaps controversially, I will assert that the collaborative identity is a triad of characteristics: extroversion, self-direction, and multi-tasking ability. And, while I will make an exception for extroversion among physicians, I won’t do so for behavioral clinicians.

In support of my triad, I believe that just about everyone who is drawn to primary care and behavioral health settings comes with some desire to improve the human condition. However, this desire manifests itself differently based on one’s professional identity. Some clinicians are tailor-made for a traditional community mental health setting that provides clearly defined roles, schedules, and patient panels. They provide amazing service to some of the most marginalized and afflicted people in our communities. Others have the entrepreneurial chops to build their own private practice through competition in the free market.

I’ve seen several of these types of clinicians fail or flounder in collaborative settings. I find that the private practice entrepreneurs never accept that they are a small, but important piece of a large and sophisticated system. They also struggle to accept that the physician is the sine qua non of primary care, whereas the behavioral clinician is the added value. Among clinicians trained for community mental health, the lack of structure and the need for constant networking can seem tedious. They find the daily onslaught of new referrals and "other duties as assigned” maddening and would much rather provide continuity services to a known patient panel.
Perhaps controversially,
I will assert that the
collaborative identity is a
triad of characteristics:
Extroversion, Self-direction,
and Multi-tasking ability.

In contrast, the great collaborator draws energy from the non-stop, unpredictable heterogeneity of integrated practice. We couldn’t tolerate the drudgery of eight 50-minute hours. We would also feel terribly hampered by not having "our team” to help out. And by "our team”, I don’t mean the other behaviorists, I mean the nurses, front desk, case managers, and physicians of my pod. Rather than feeling competition by sharing care with clinicians with different skills and scopes of practice, we are drawn to being a round peg in a square hole. And, based on the developmental newness of integrated care, rather than being intimidated by cutting new trail in our professional settings, successful collaborators share a pioneering spirit.

Those are my beliefs about the collaborative professional identity. I’m hopeful that the next posts in our series will:

1. Contradict many of my assertions;

2. Explain how this identity can be trained;

3. Expand the discussion to be more relevant to medical clinicians.


Randall Reitz

Randall Reitz, PhD, LMFT is the founding editor of CFHA Blog and Families and Health blog. He is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO where he directs a collaborative training program for family physicians, medical family therapists, and psychologists. He is co-chair of the 2013 CFHA conference in Denver, CO.

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CJ Peek says...
Posted Friday, May 3, 2013
I enjoyed reading your blog post—and agree that "identity" is an important thing to include in training and orientation to collaborative care roles. Very nice to place "identity" in that Chickering model and go on from there. The 3 characteristics (extroversion, self-direction, and multi-tasking ability) are an interesting capture of the personal side of this.

While training or supervising people for PCBH practice years ago, I felt the need to take a stab at the "identity question" because the role was unfamiliar to most PC people, and the BH professional would have to claim the proper status from the start within the social architecture of that clinic. That meant the person had to be able to articulate their incoming identity accurately, briefly, and thoughtfully on the first day.

Before being assigned to a PC clinic, MH professionals had to formulate for me their answer to this PCP question on their first day, "So who are you and what do you do?". They had to get this down quickly and comfortably before they could start. To help them create their elevator speech, I suggested they ponder their primary care identity by putting this into words first: "who am I and what do I pay attention to?". This for me was the identity question—not so much traits, but what you see and do as a PCBH person, knowing you may wear other hats during other parts of your workweek*.

Of course, I recorded the various thoughts we all had on this and created a teaching piece so that people didn't have to reinvent this all the time. I also used this as a barometer of interest during hiring processes. Can the person relate to this shift in identity for going into a PC clinic? Are they excited or merely, "I could do this if I have to"?

Those teaching pieces appear on pages 9-12 of the attached syllabus. You may have seen some of this before, as it is old stuff, but perhaps still relevant to the "identity" question, see here:

1) MH expertise positioned in two ways—as a specialty and as integrated in medical care
2) Therapist identity: "who I am" and "what I pay attention to"
3) From soloist to ensemble-ist: An aspect of good clinicianship
4) Care management mottos across disciplines as elements of good clinicianship

Looking forward to the other editions of that blog.


* Background thinking behind this question: (Quoted from Putman, AO, 1998. "Being, Belonging, and Becoming", Descriptive Psychology Press):

". . . . Being a banker, I am conscious as a banker. I look for opportunities to do what a banker does; I pay particular attention to those states of affairs of interest to a banker; I appraise and respond to a situation in one of the ways a banker does. As the third baseman on our softball team, I am conscious of a very different set of things because I am conscious as a third baseman – not as a banker. This is an ordinary, everyday fact about persons: what we are conscious of depends largely on who we are conscious as, and this changes routinely and dramatically as we change who we “be”"

The idea here is "identity", not trait—and that identity or "hat" can change. Hence a psychologists can shift from being conscious as a PCBH person to a specialty MH person to a banker or a father or whatever. The challenge for training is to get the default "conscious as as mental health specialist" to become "conscious as a primary care behavioral health consultant" and then to have the flexibility to back and forth when your role changes.
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Jackie Williams says...
Posted Friday, May 3, 2013
Ouch! Liked everything except the extroversion part.

Controversial, indeed!

Introverts make great collaborators and relationship builders in integrated care. We just do it differently. Sounds like I need to do a blog post on being an introvert in integrated care...
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Barry J. Jacobs says...
Posted Friday, May 3, 2013
I just happened to attend a Primary Care Behavioral Health presentation today by Neftali Serrano at Philadelphia College of Osteopathic Medicine. He commented that what makes a good (or bad) behavioral health consultant is "temperament"--not extraversion per se but the ability to flexibly go with the flow of multiple tasks, personalities and challenges in the course of a clinical day. As he put it, to be a little ADD. I think this is closer to the answer about the essential identity of a behavioral health collaborationist though it also raised the question of whether that essence is inborn: You are either born with it or not. If that's the case, then all those graduate school readings are probably for naught.
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Randall Reitz says...
Posted Monday, May 6, 2013
CJ, Thanks for adding your wisdom to this conversation. I love the simplicity of "Who I am, What I pay attention to". That does encapsulate identity quite well.

Jackie, Are there ways in which being a self-avowed introvert is beneficial in collaborative care, or do you find you try to work around it?

Barry, I agree that temperament is a good addition to this discussion. It challenges my assertion that success is a personality type. I don't agree, however, that ADD is helpful. My own ADHD tendencies need to get reined in so I can pay attention to the details of charting, following-up and following through. Mania might help, but not distractability. I hope that global collaborative acumen isn't in-born, but certain aspects of it definitely are (i.e. introversion vs extroversion). If I were to re-shuffle my "Big 3" I would say that the 2 most important traits are: niceness and awareness of one's role within the larger system. Those can both be ingrained.
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