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Sound but Flexible Identity Development: A Challenge for Behavioral Clinicians

Posted By Tom Bishop, Thursday, May 9, 2013
Developing a Professional Identity
Tom's post is the 2nd installment in this series.  You can read the first post here.

I certainly appreciate Dr. Reitz’s assertions of a developmental progression in professional identity formation as one prepares to work within integrated care. It does seem intuitive that one would pass through each of Chickering’s seven "vectors” as they progress through training and service as a primary care provider. It is also seems plausible, and very much supported by observances in the field, that there is a personality style, or as Dr. Reitz postulates, a "collaborative identity” that tends to lend oneself in being a good "fit” for serving within integrated care.

That said, I believe that taking another pass at McDaniels et al (2002) curricular article may provide more clarity to why some clinicians excel at integrated care and embrace innovation over traditional roles. McDaniels comments, "Psychologists-in-training need to develop the skills that solidify their identity as psychologists” and that having a "positive professional identity” would serve one well in working within primary care.

I am led to recall an experience I had with a couple of students in training. They were sharing the tension they experienced in learning the core skills and attributes of what it means to be a psychologist while considering what their work would look like within a primary care setting. They voiced concern that working in an integrated care setting, especially at that start of the training, would be too "narrow,” and limit the development of their clinical skills in some way. I believe that these concerns are closely tied to how one understands what it means to be a "psychologist.”

More recently, the field of psychology has begun gravitating back toward a more comprehensive identity. I say "gravitating back” because Lightner Witmer who is considered by many to be the father of modern clinical psychology understood psychology as collaborative, scientific, and as a catalyst for addressing problems. According to one reference: "Witmer never intended for clinical psychology to become segregated from other helping professions, particularly medicine and school psychology” (Brown, Prime, & Wade, 2012, pg. 1). However, this vision for the field has not been the prevailing image or impetus of training. "Indeed, Witmer envisioned a unified yet multifaceted discipline that possessed many progressive and innovative ideas that were lost or ignored over the course of the 20th century”
(See pg 2 where Brown et al discuss Routh, 1996).
One reason clinicians
may flounder within integrated
care is that they have come to embrace a more "contained” perception of what it means to
be a clinical psychologist,
medical family therapist, social worker, or school psychologist

Put broadly, then, one reason some clinicians flounder within integrated care is that they have come to embrace a more "contained” perception of what it means to be a clinical psychologist, medical family therapist, social worker, or school psychologist, and that perception is inherently independent rather than collaborative.As a corrective, training programs might emphasize the importance of core, foundational skills that would allow a behavioral clinician to collaborate with others rather than become "soloist.” It may also be critical to stress that our training allows us to be good at what we do, and that we are not to become something that we are not. Elliott and Klapow (1997) suggested that "We must broaden the professional options for our trainees by emphasizing behavioral science expertise versus mental health service provision.”

In returning to Dr. Reitz’s discussion of Chickering’s model as providing a means of examining professional identity formation, there is at least one other consideration. Perhaps training and early career experiences are more characteristic of what Erikson and James Marcia described as a time of crisis in one’s sense of occupational and social identity. This period of professional life is fraught with the search of "fit,” growth, conflict, and tension.

While personality is a factor, early career clinicians identification with their profession may be more characteristic in how they have wrestled with what it means to be functioning as a behavioral clinician. Some may have entered into training and work with a great deal of uncertainty and little reflection or consideration (Identity Diffusion), while others may have gone in full throttle with little exploration of what their particular field (e.g., psychology, social work, etc.) could encompass (Identity Foreclosure). Still others may truly be in crisis where they are unsettled and desire more from the work that they are doing, which seems to fit Dr. Reitz reflections on establishing identity (Identity Moratorium).

Perhaps "controlled and supported crisis” is what may be helpful in training and in challenging trainees to consider a broader conception of their discipline. It may be that McDaniel and the other authors were speaking of Identity Achievement when they commented how having a solid identity would prepare one for working within integrated care. They would possess the core understanding, skill set, and commitment for what it means to be a psychologist.

In summary:

  1. The success of a clinician in integrated care is inherently linked to how we portray, teach, and model a comprehensive understanding of what it means to be a particular behavioral health discipline, whether that is a psychologist, social worker, medical family therapist, or any other. Trainers want to foster the development of a sound identity for that discipline.
  2. At the same time, trainers could do better at challenging trainees in developing broader skills and in challenging their notions of what it means to be a psychologist, social worker, etc. It seems that this would be facilitated by having training opportunities that are more inter-professional and collaborative. These opportunities would, perhaps, create conflict and crisis in roles and functioning within an interdisciplinary team.
  3. While personality is certainly a factor in what leads one to consider a career in integrated care, this could be said of any profession, ie…why does one person become a plumber vs an engineer? Perhaps an analogy would be the contrasts of a jazz musician who is classically trained and a musician of another genre of music – they are each well versed in the foundations of their craft, but express these skills in varying ways.

I am certain and hopeful that the next response will challenge many of these premises.


Thomas Bishop

Dr. Bishop joined the faculty at the Johnson City Family Medicine Residency program at ETSU/Quillen Medical School in March of last year after serving several years with Cherokee Health Systems as a Behavioral Health Consultant and pediatric primary care psychologist. Thomas received his Psy.D. in Clinical Psychology from Wheaton College with an emphasis in the integration of psychology and theology, and a Masters degree from Central Michigan in general experimental psychology with an emphasis in brain injury and recovery of function.  His professional and research interest include primary care, rural and organizational health, faith and medicine, positive psychology in medical care, sports psychology, and neuropsychology. Perhaps most important, he and his wife Barb, who is brilliant in math, and have three children, two in college and one that thinks she should already be in college. They are often found together on a trail, running, or camping.

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Laura Sudano says...
Posted Thursday, May 9, 2013
I appreciate Dr. Bishop’s note on modeling a “comprehensive understanding of what it means to be a particular behavioral health discipline” and encouraging trainers to “foster the development of a sound identity for that discipline.” These past two blogs by Dr. Reitz and Dr. Bishop have afforded me the opportunity to reflect on and solidify my identity development as a Medical Family Therapist particularly within the hospital setting.

Since I've returned to Inpatient Medicine Teaching Service (IMTS), or inpatient rounds, from my recent hospitalization, I always go to the nurses' station and look at the board to see who the RN (or if the RN isn't available, the CNA) is for that patient. I ask to speak with them about how the patient is doing and if there have been family members coming in to see them. I ask the RN/CNA if they witnessed any mental health related issues during the patient's care, e.g., is the patient more down today than other days? Has the patient been experiencing more anxiety than other days? etc. Despite my introduction, "Hi, I'm Laura Sudano. I work with Family Medicine as a Medical Family Therapist," I continuously get asked halfway through the conversation, "Wait, who are you?" I repeat the introduction and they state, "Oh, so like a behavioral health person."

I share that because that is a common response to which I repeat the language, "Medical Family Therapist." My belief is that if I say it enough times to enough people, the language will then be used at the hospital. I am hesitant to ditch the Medical Family Therapist identity despite "behavioral health person" being a commonly understood title in the hospital. I was trained in marriage and family therapy with an emphasis in medical family therapy, and through my training and experience, I now identify as a Medical Family Therapist.

But in the hospital setting, where does specialty end and layman’s term begin? Do we relinquish identity for others to understand what we do? Is “relinquishing” even necessary? Applying Bowen family systems to identity within the mental health field suggests that there could be healthy differentiation and boundaries. That is, we can individuate just as the RNs do from the CNAs while respecting the profession’s boundaries. As a CNA, one is not able to draw blood from a Hickman catheter/port. Instead, the CNA will call an RN to do this work. Health care providers (I use the term “providers” as all those working in health care) are not familiar with each profession and skill set. A CNA and RN are nurses, just as MedFTs, psychologists, psychiatrists, school psychologists, and social workers alike are mental health providers. All aforementioned specialties work together to help individuals, which inherently is collaborative in nature. However, as I mentioned above, I choose to stick with repeating the language in hopes that second order change will be with us one day and we can learn who is trained to draw from what port.
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