Imposter Syndrome / Phenomenon

College of Intensive Care Medicine of Australia and New Zealand ABN: 16 134 292 103

IMPOSTOR SYNDROME / PHENOMENON

I have written 11 books but each time I think ‘Uh-oh, they’re going to find out now. I’ve run a game on everybody, and they’re going to find me out.’ Maya Angelou

There is a psychological experience of perceived fraudulence that is common among highly successful individuals including health professionals. Known as impostor syndrome, or imposter phenomenon, affected individuals have intense beliefs that their achievements are the result of luck or other external factors rather than ability. While outwardly they may appear confident and capable, internally they feel anxious and uncomfortable believing that they are living a lie, worrying that their successes are undeserved, and convinced that they will eventually be exposed as a fraud. They often struggle quietly.

Imposter syndrome was first described in the 1970s, and while it is not a psychiatric diagnosis in itself, the experience of impostor syndrome can be measured using published psychological assessment tools, and has been found to be strongly associated with psychological distress, impaired wellbeing, and the development of anxiety and depression in health care professionals and trainees. Furthermore, there are clear harmful associations between the presence of impostor syndrome, impaired job performance and satisfaction, and the development of burnout.

Individuals who experience impostor syndrome are thought to have developed maladaptive cognitive processes during childhood that cause them to fail to appropriately internalise their successes. They develop a fixed mindset that is dismissive of positive feedback and contributes to avoidance of tasks with high prominence or visibility. It is likely that these maladaptive processes arose due to a combination of family environment, family dynamics, parenting style, and personality traits such as perfectionism and neuroticism. As adults working in areas that are traditionally critical and intolerant of failure or imperfection, such as healthcare, these maladaptive processes can constrain learning and development of professional identity, and ultimately impair career progression.

It is proposed that the imposter syndrome is marked by six characteristics:

 The Impostor Cycle An achievement-related task generates anxiety within an individual who reacts by extreme over-preparation, or initial procrastination followed by frenzied preparation. Following successful task completion, the sense of accomplishment and relief does not persist. Despite positive feedback on their task performance, individuals with impostor syndrome who have overprepared, inappropriately attribute their success to hard work rather than their real intellectual ability. Those who initially procrastinated tend to attribute their success to luck. Failure to recognise the mechanics of successful task completion and achievement results in new achievement-related tasks being met with self-doubt and anxiety, setting up a detrimental cycle.

 The need to be special or to be the very best Often at the top of their class during schooling, when placed in a larger setting such as medical school, individuals with impostor syndrome realise that their own talents may not be exceptional. Comparison with others of equal or higher ability leads individuals with impostor syndrome to conclude that they are inadequate or deficient because they are no longer seen as the very best.

CICM Welfare Special Interest Group, April 2021  Superman/Superwoman aspects Perfectionist tendencies drive people with impostor syndrome to expect every task to be completed flawlessly. Unrealistic standards and perfectionist goals overwhelm, disappoint, and lead to an unreasonable conclusion of self-evaluated failure. .

 Fear of failure Fear of failure during the performance of an achievement-related task leads to high levels of anxiety. Mistakes, and failure to perform at a high standard, lead to shame and humiliation. To avoid failure, individuals tend to compensate by overworking.

 Denial of competence and discounting praise Praise is not easily accepted and is not internalised as valid by individuals with impostor syndrome. They tend to discount positive feedback and objective evidence of success, instead focusing on reasons why they do not deserve praise or credit. This is not a false display of modesty, but a genuine belief that praise is undeserved.

 Fear and guilt about success Individuals with impostor syndrome may perceive negative consequences relating to their success. In particular, if their achievement is unusual for their family or peer group, a sense of disconnection and guilt at being different can lead to a fear of rejection by others.

People with impostor syndrome do not measure their competence by their successes. Instead they produce their own set of internal standards by which they assess themselves, but which they never see themselves as achieving. These self-imposed assessments of competence give rise to a number of subtypes of impostor syndrome with characteristics that are readily identifiable among medical professionals and trainees:

Subtype Characteristics

Perfectionist Perceives competence as 100% perfection. Anything less is considered failure. Always focuses on how something could have been done better.

Natural Genius Measures competence by how easily the achievement came to him/her. Hard work and perseverance are considered negative traits because there is a belief that success should come more naturally.

Superwoman/man or Perceives competence as the ability to juggle numerous roles and Super-student responsibilities simultaneously. Underperforming in a single role constitutes overall failure even in the context of major successes.

Expert Measures competence by volume of knowledge or skill. Fears being exposed as inexperienced because of lack of knowledge.

Soloist Perceives competence only if an achievement was obtained completely on their own without the aid of additional resources. Asking for help is considered a sign of failure.

Recognising and managing impostor syndrome in ourselves, our colleagues, and in our trainees is not easy. Often individuals with impostor syndrome do not disclose their inner concerns due to the fact that they are afraid that they will be discovered to be a fraud. Acknowledging that it is normal to have some feelings of self-doubt is important, but it is also important to realise that these feelings

CICM Welfare Special Interest Group, April 2021 should not lead to a belief that success is not deserved. Raising awareness of impostor syndrome, identifying trainees and colleagues who are struggling with impostor syndrome, and encouraging them to seek assistance are among a number of strategies that can be used to address these negative thoughts and maladaptive behaviours.

Strategies to manage impostor syndrome

 Recognise, acknowledge, and share feelings of impostor syndrome with trusted colleagues  Realise you are not alone  Ask mentors and trusted colleagues for objective and truthful feedback  Reference your personal career success inventory  Practice self-compassion  Maintain a growth mindset  Practice thought-stopping  Seek professional assistance from a psychologist or trained counsellor

Performing a career success inventory of personal achievements and identifying the core skills that brought about those achievements is more useful than trying to identify personal strengths and weaknesses. This is often difficult for individuals with impostor syndrome to perform objectively on their own, but may be built into a mentoring or coaching relationship. Mentoring may also provide a longitudinal perspective on achievement and competency that can gradually expose impostor feelings as irrational and unjustified, and may help the mentees build a more functional professional identity.

Breaking the maladaptive cycle of thinking that creates impostor syndrome using cognitive techniques such as thought stopping, the mindful replacement of negative thoughts with something more positive, often grounded in self-compassion and self-kindness, may help reduce self-criticism. These techniques are often best learned during professional psychotherapy and counselling sessions.

Finally, the environment and culture created in the medical workplace has a significant impact on how individuals identify themselves relative to their peers. Exposing the inadequacies of individuals leads to humiliation and embarrassment that suppresses intellectual curiosity and worsens feelings of impostor syndrome. Such an environment results in individuals with impostor syndrome withdrawing from participation unless they are confident of success. Creating an environment for collegial learning and professional growth as opposed to an environment of competition and comparison provides a more stable, and less stressful, performance motivation. Encouraging learning through support and guidance may better allow individuals with impostor syndrome to achieve career goals while maintaining wellbeing.