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Caroline Giroux MD
In medical training, we learn about specific defense mechanisms. We read in textbooks or see in patients we assess a variety of ways people try to cope with stress. They of course can apply to any of us, and the various permutations will depend on core beliefs or schemas the persona has developed, individual idiosyncrasies, and ways the environment/culture has modeled specific strategies. There are various ways to categorize them. We will address the ineffective ones (even self-destructive at times) first, then proceed to more adaptive coping styles.
Coping mechanisms are part of our self-preservation system (see section Know Yourself, topic Personal Adversity on a Continuum between Resilience and Burnout). They are not necessarily bad per se but it is the rigidity and chronicity of use of primitive ones that can become problematic. In medicine, for instance, the core beliefs or schemas shown in Table 1 are prevalent and tend to give rise to specific coping mechanisms.
| Core belief / Schema | Coping style |
|---|---|
| “I have to be perfect” | Rigidity, restricted affect |
| “Everything has to be done perfectly” | Controlling behaviour |
| “I have to prove my talent, competencies” | Competitiveness |
| “I don’t need to sleep or eat like most humans” | Self-sacrificing attitude |
| Helplessness, powerlessness (from years of harsh training) | Avoidance, procrastination |
Do you identify with any schemas and coping behaviours listed in Table 1 above?
Can you come up with other ones? Please list them in the empty Table 2 below and find healthier alternatives to these maladaptive schemas and strategies.
| Dysfunctional core belief | Maladaptive coping style | More accurate principle | Adaptive coping strategy |
|---|---|---|---|
Often, we create our own mental prisons. Read the information in Table 3 and see if you can add other pro-burnout illusions you have noticed in yourself or your peers.
| Pro-burnout illusions | Pro-resilience values |
|---|---|
| Emphasis on a specific outcome | Non-attachment to outcome |
| Rigidity | Open-mindedness, flexibility |
| Seeing mistakes as failures | Seeing mistakes as lessons and stepping stones |
| Personal value equated with grades or success | Personal growth emphasized |
| Need for perfection | Desire for excellence; embrace vulnerabilities |
| Overidentification with external measures of success | Meaning, purpose |
| Intimidate, never show signs of weakness | Compassion; kindness |
| Money will compensate for life dissatisfactions | Viewing one’s role as part of a bigger whole |
| Achievement of the professional identity | Transcendence; be in the “zone” or “flow” |
| Omnipotence (“no one else can do this job well”) | Humility and collaboration |
| Caring-killing paradox* (in palliative medicine, geriatric medicine, etc) | Joy in every moment Mindfulness: non-judgmental observation |
| Rescuer syndrome | Acknowledging one’s limits: sign of competency |
| Pseudo-independence | Connection, sense of community |
| Looking for differences, polarization of ideas | Looking for similarities in people Intersection |
| Obeying constraints to be recognized | Creativity, innovation |
| Debate | Dialogue |
| Reactive | Responsive |
Image courtesy: Caroline Giroux
Even though perfection is a myth, a lot of people still strive to attain it. Perfectionism is a set of attitudes, expectations and behaviours that derive from a desire or need to attain perfection.
Signs of perfectionistic tendencies:
Perfectionism has been an adaptive trait to be admitted to medical school given its requirement of high performance. However, the emphasis had been put mostly on fund of knowledge to perform on exams. Stress management and competency development also need to be emphasized, and this is what the RESPITE initiative aims to help with.
For example, at University of California, Davis, the field of psychiatry has become increasingly competitive (two candidates who had applied and had a great potential did not match for 2018). Just through the admission process to medicine, we also select a sample of people who are high-achievers, ambitious and also possibly neurotic (notably: a significant proportions of medical providers have a history of adverse childhood experences). This is a double-edged sword in the sense that their vulnerabilities can be their strength when there is awareness of them, when channeled properly and when self-care is maintained, but a major problem when it becomes a blind spot and there is overachievement at the expense of personal needs.
Ways to challenge perfectionistic attitudes:
Understand what the desire to control is about, what the person is trying to defend against, and what vulnerabilities the person is trying to hide.
List of resources on more Zen approaches: