Addressing the Mental Health Struggles of Healthcare Professionals: Breaking the Cycle of Punitive Superegos
In part one of my series on healthcare providers’ mental health I explored how perfectionism contributes to the disproportionate incidence of depression and anxiety in healthcare professionals. While I mentioned “the fear of punitive consequences” when perfectionist standards are unmet, the article did not delve into their fundamental nature. The aim of the present article is to probe into 1) the underlying psychodynamic factors that contribute to this punitive frame of mind and 2) the role this mindset plays in depression and anxiety of healthcare professionals.
A Punitive State of Mind – A Psychodynamic Perspective
The term "punitive state of mind" refers to a negative mental state characterized by a desire––in this case an inclination––to inflict punishment or seek revenge. It can also refer to a mindset focused on blaming and fault-finding at the expense of seeking constructive solutions or learning from mistakes. This state of mind can lead to inner and interpersonal conflict, potentially harming the affected individual and their colleagues.
In my practice, I have seen this manifest as individuals who embrace a psychological state in which they are excessively harsh, critical, and judgmental towards themselves or others. This can arise from early experiences of punishment or criticism from caregivers, leading to the development of what is known as a harsh and punitive superego. Another term for this is the ‘inner’ critical voice.
Individuals with a punitive superego experience feeling of guilt, shame, and self-blame, and may struggle with low self-esteem and self-worth. In psychoanalytic terms, this harsh internal critic is a manifestation of the superego, which operates as an internalized representation of parental mistreatment. Patients often talk about caregivers who were apathetic, cold, hostile, attacking or overly anxious or involved. In short, these patients experienced disturbances in optimal caregiver availability.
The Importance of Optimal Caregiving: Developing a Healthy Ego-Ideal
When individuals experience optimal caregiving, they develop a sense of an ideal self or an ego-ideal. This represents an internalized representation of the positive qualities and values that the individual has learned from their caregivers. The ego-ideal is a key component of healthy psychological functioning, providing a sense of self-worth, motivation, and direction for one's goals and aspirations. It is not over-inflated, as was discussed in my first article on perfectionism. Therefore, we can safely measure our real self against our ego-ideal. An example of this is the physician–– mentioned in my prior article––who is not able to write patient notes because the notes need to be flawless and perfect. When that “ideal” image of the notes cannot be reached, the physician believes they have failed. However, this is no ordinary failure because these individuals have a punitive and harsh superego that is always ready to judge, berate them, and inflict harm. The superego is loaded with aggression, and it will find any reason to attack the self––similar to how this individual was attacked by their caregiver!
An Example from My Practice: Psychodynamic Treatment in Action
The following example from my practice represents the impact of a punitive superego and an unrealistic high ego-ideal (i.e., perfectionism). To protect anonymity, this case is presented as a composite of many patients' experiences.
In this scenario, the physician in question felt that every patient note must be meticulously crafted and error-free. This individual, whom I will call Sarah, was raised by a mother who was critical, condescending, and verbally abusive when Sarah did not immediately understand something her mother was attempting to teach her. It was not uncommon that she was called “stupid” while her mother asked her, “What is wrong with you!” Sarah internalized her mother's harsh and punitive voice, and as a result, developed a ruthless superego that constantly criticized her every move.
Like many individuals made to feel worthless, Sarah over-compensates and inflates her sense of self by developing a high ego-ideal. In other words, she has an unrealistic idea of who she wants to be and how she “should” perform. The greater the distance between one's ideal self and their actual self, the more deflated their self-esteem. Sarah would undervalue realistic achievements, struggle to accept compliments, and constantly devalue herself.
In treatment, I helped Sarah examine her high standards, including her need to write perfectly crafted patient notes. Gradually, I helped her to reflect on the impact that these standards had on her sense of self-worth. Sarah began to realize that when she fell short of her ideals (e.g., by falling behind on her record keeping), she was punished by both administrative staff and by her superego, the latter often more severely. In therapy, Sarah initially saw herself as a constant failure, but as we continued to work together, she started to see her failures in a different light. She began to recognize that feeling like a failure was not the same as actually being one. Instead of seeing herself as "stupid" or a "loser," she started to distance herself from what she could now see was the voice of her mother.
With time, I was able to help her question, understand, and subsequently silence this harsh inner critical voice. Sarah learned to respect herself, so that, when her inner representation of her mother tried to abuse her, she was able to say, “Get out of here. I am not a bad person, and I know I am not stupid.” This work was no easy task, and it involved a great loss (detailed in the previous article). For so long, Sarah had identified with the critical voice of her mother. In separating herself from this voice, Sarah lost this internal representation, an aspect of her identity to this point. Thus, a portion of our work together focused on coming to terms with her newfound freedom from the voice. While this allowed her to become more confident, self-assured, and positive in her work it also required a process of relinquishment and mourning for the part of herself that was tied to that representation.
In this article, I have explored the relationship between a punitive superego and the mental health of healthcare professionals. Psychodynamic therapy can help individuals to identify, quiet down, and, in many cases, put to rest these internalized critical voices, leading to greater self-compassion, self-awareness, and self-acceptance.