Friday, 8 November 2013

We’re (not) coming out… Not today, anyway

Salomons Service User and Carer Coordinator, Laura Lea considers why admitting to mental health problems may be such a taboo for mental health professionals.

https://r3.res.outlook.com/owa/14.16.292.0/themes/resources/clear1x1.gifhttps://r3.res.outlook.com/owa/14.16.292.0/themes/resources/clear1x1.gif
McGowan, John (john.mcgowan@canterbury.ac.uk)
Lots of attention since we tweeted it actually. Several retweets, favourites etc. Be interested to se if that shows up in the figures from the journal’s website.
Fri 26/04
Victims of care crisis? Or psycho
killers? Who'd want to come out.
'We're comin’ out… out on the streets’ sang the late Lou Reed. That was in 1972 and now feels part of a story where people having the courage to be honest led to a sea change in attitudes to sexuality. In 2013 it still rarely feels safe to tell people I've had mental health problems. Even before that notorious Sun front page. I'm not sure what I think will happen if I declare myself. Perhaps it’s a belief that people will wonder whether it’s me or the mental illness talking. Too much emotion might be taken as a sign that I am not entirely in charge of myself. Too calm and my responses could seem blunted. Either way I don’t want people to think that my brain is out of order. After all there’s plenty of evidence to suggest admissions of mental health problems provoke pejorative associations and might not be the best thing for my future employment prospects.

In my current career though (someone whose current job actually requires experience of being a mental health service user) I'm more out than I've ever been. While it’s not always easy, I hope I’m at least a small part of a bigger change, and that coming out can be as powerful an act in mental health as it has been in sexual identity. I often wonder though how much more difficult is it to declare you have a mental health condition if you actually work in the business? Certainly a recent study of psychiatrists suggests this is the case. What if you go from being someone who is known as sane, even a sanity consultant’, to someone touched by madness? The study suggests that maintaining your secret is the only answer. Doctors need to hide their status as patients.

The question for me is whether something important gets lost when mental health professionals simply hide their own vulnerabilities: an opportunity to connect with service users and signal, in the most immediate way possible, that they are not alone. That the carer and the cared for, share a profound area of common experience. It’s a tough one though, and clearly professionals mostly want to keep it under wraps.
Some of my Salomons colleagues and I thought it was time to find out more about the issue. We recently ran some focus groups exploring how difficult it can be for mental health professionals (in this case clinical psychology trainees) to speak about their own experiences of difference. Difference in this case might be experience of mental ill-health but also gender, sexuality and disability. The resulting paper Finding the Personal in the Clinical Psychology Swamp (the title an attempt to acknowledge the messiness inherent in these situations) has now been published. Through our discussions we found that people were hesitant and anxious about voicing all kinds of difference. Experiences of class, parenthood and mental health were all hard to integrate into a clinical identity. When we held a related seminar open to all our staff and trainees, people came forward to speak about a number of experiences. These included being a parent, a carer or having a physical disability. However, we were unable to find someone to speak about being identified with mental health issues.  If people are silent we can only guess at their experiences and motives, but it seems to me that talking about this subject is just too complicated for a lot of people.

In one way, we've simply confirmed what we already know. It makes me at least think that perhaps ‘them and us’ thinking persists, not only out there in Sun journalists, but also among mental health professionals. Perhaps that’s an unfair conclusion but I find it difficult to avoid. However, hopefully by raising the issue we are giving people the opportunity to think about the reasons that they are reluctant to speak up. The next steps for us are to investigate further into the reasons for this reluctance and, in the longer run, to think about ways to change things.


Are you a professional with an opinion on why a user history is difficult to confess to? Or a user of health services who would like to know more about those who treat you? Comments are open and we’re interested in your views.

24 comments:

  1. I wonder though. As a professional (parcticulatly as a counsellor or psychotherapist) might you not want to be a bit unknown?

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  2. The absence of views from psychologists is conspicuous though unsurprising. It contradicts the oft cited 1in 4. The silence speaks volumes & also reflects how comfortable the position of "trained expert" is.

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  3. Perhaps true but may be many other reasons I suspect. I'd be interested in hearing them from readers. (John McGowan).

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    1. Fear of being monitored unhelpfully by management. Fear of colleagues reactions. Fear of losing credibility. Fear of being professionally ostracised

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  4. Fear of being stigmatized and ostracized mostly by colleagues, not clients, which will result in loosing credibility and professional isolation. This fear is absolutely reality based as these things do happen when professionals "come out" and talk honestly about their vulnerabilities and their quest for help.

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  5. As a psychotherapist I value my anonymity because it allows the people I see to make of me what they will. We explore that together. My own personal history would, I think, muddy the waters. Jane.

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  6. Great and brave article Laura. I think it raises lots of questions though in terms of what you are asking mental health professionals to do. Who do we define as a 'service user'? Is that specific to someone who has used NHS MH services, or someone who has been willing to engage with their own material in other ways (perhaps private personal therapy). I think the battles users of the NHS suffer are different from the battles someone in good private therapy suffers: one battles only their own darkness, demons and pain, and the other must also deal with a huge and massively under-resourced system in which people's needs can be lost. What would 'coming out' look like to you? As a psychologist who has certainly experienced a history of trauma with the concomitant difficulties in emotional and relational regulation that that can entail, I have had years of private personal therapy, and draw on that experience (in an appropriately boundaried and reflective way) in my clinical work. However, I am sensible of my privilege, the choices i have had that have not been possible for many of my clients, such as access to long-term private therapy-I do not claim to have suffered what they have suffered because that undermines their journey and the particular difficulties they have faced that my relative privilege has helped me to avoid. I use the power of my position to advocate for clients or those who do not have a voice, and I speak openly to colleagues, supervisors, other professionals about the fact that I have had therapy, that emotions are healthy, that we need to come always from a place of compassion. If a client asked me directly if I had had personal therapy myself I would acknowledge it, because it helped me when my therapist did, and because I think it breaks down the power differential if I can show myself as someone who has needed help. I would leave it there though, the focus is on them, its their therapy. That is what stops me 'coming out' more explicitly and directly than I do already, and why I am posting anonymously just now-I don't believe it's helpful for current or future therapeutic relationships if my clients know too much about me. My final thought is that I don't, and never have, see myself (or my clients) as someone who has 'mental health' problems-I just don't like that term and find it pejorative. As a psychologist, I formulate, and people's difficulties always make sense in the context of their life events and experiences. So labelling them as someone with a 'problem' or a 'difficulty' is uncomfortable for me both as someone who has had some pretty difficult experiences and a clinician. I find it more helpful to speak in terms of attachment, survival, the unconscious, how the mind copes with extreme or chronic fear or neglect-my clients and I are ultimately both just little humans experiencing the pains of existence and trying to figure out how we live in this world in a way that is meaningful to us. I 'come out' as that every day.

    I'd be interested to hear your answers to my questions: it's an important and interesting debate Laura, thank you.

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    1. Anonymous from above continued: I just wanted to add that I do see myself as being relatively 'out', and have never experienced anything other than support from managers, supervisors, colleagues. A couple of other respondents have named that fear above but it hasn't been my experience at all. Actually people have often disclosed their own personal therapy to me in turn, or been able to speak about a family member's suffering. I talk about my personal therapy all the time, because I think it's important and de-stigmatising, but other psychologists I know who have also had therapy and done that work on themselves do not make the choice to do so, and I respect that. So the final question I would pose to Laura is-why? Why try to push or force others to name their suffering explicitly if they have chosen not to do so? What is your hope for what it will achieve? People working in MH have chosen to do a job where they help others, and many people with wounds of their own are drawn into this work, and learn, and push themselves, and grow and heal as a result. If they then want to continue to do their part by working in an incredibly tough, painful and demanding job, in an underfunded and overstretched NHS, with frequent threats of cuts and overwhelming caseloads, and choose to spend their time outside work living their lives and doing things that nurture them, why can't their choice be respected? What would their admission, that they are people just like you, who may have suffered just like you, mean to you?

      best wishes,

      Pink

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    2. Pink again-one more thought, then I'll stop!

      I want to acknowledge, before I begin writing this, that people experiencing more severe or enduring difficulties, such as psychosis, have often had a pretty bad experience at the hands of the NHS. I have worked with people who have been frightened and traumatised by their treatment when actively psychotic. The system has kept them alive and safe when they could not do this for themselves, but the steps taken to achieve this have, at times, been agonising, painful and traumatising. I absolutely do not wish to dismiss their suffering, and I think the service user movement is vital in giving a voice to those who have not been heard.

      However, and I am going to sound very psychodynamic here but that's how I make sense of this, I do feel sometimes that the rage in the SU movement, and this article's request for 'accountability', and admission of weakness or flaws from the deliverers of the services, is actually a very early rage playing out. The NHS cannot undo what was done to you, your therapist cannot love you enough to heal you, and no-one ever could. No-one can make it go away, or protect you from future harm. You are, we all are, alone in this life, with our pain and our despair, and the hopelessness of that is agonising. All your therapist can do is help you to bear that pain, think of strategies you can use, process some of the trauma, and connect you to the things that make life meaningful for you. That's it. They are, and we are, flawed and vulnerable human beings, and in requesting that they admit that I do wonder if that is an attempt to reclaim some power, to avoid the despair of realising that ideal care does not exist, that no-one can make it all better. I say this myself very much as someone who has been a client and been to that really dark place in my own therapy, experienced the rage, powerlessness and despair, and been fortunate enough to have a therapist who hung in there through all the shitstorm of punishment I gave her for that. It was humbling to realise, when I came out the other side of it, that she had been beside me all along, doing the best she could. The sadness of the lack of resources in the NHS, in my personal belief, is that we are not able to stay alongside clients long enough for them to process this early pain, or find their way out of it again. People find other ways of coping, many use services successfully, take what they can and move on with their lives, but others remain trapped in their anger and suffering. I wish, with all my heart and soul, that as a clinician I could give those people what I've been given, a generous and compassionate therapist who hung in alongside me over a long period, who understood what was occurring and who could bear it for both of us, until I could take it back from her again. I think that's what the service user movement is often asking for, and I hope that their voices can be heard. It's an important and legitimate request.

      take care,

      Pink

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  7. I am not a mental health professional, I am an academic, and I am not speaking about myself. I am speaking about my sister who is a senior health professional (but again not mental health) and who has issues with depression. My experience is that my sister has failed to see the signs of her own deteriorating mental health because of her focus on other people as the ones needing help, and also because her own professional status, and having high self belief and self motivation, she has been willfully blind to the consequences of her behavior.

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  8. As a trainee with a history of using mental health services, I can relate a lot to Laura's early comments about worrying that once 'out', my actions will be interpreted by others through a lens of 'mental illness'. However, I felt that the discussion lacked a couple of critical points relating to mental health professionals' own experience.

    Although I am reasonably ‘out’ to friends and family and don’t mind discussing my history to some extent with colleagues and other trainees, I don’t talk about it with clients I am working with. This comes from no wish to deny them the chance to see the similarities between us or maintain a power imbalance. On the contrary, I don’t share my experiences because I think it might be actively unhelpful to them. My teaching and the guidelines surrounding my work recommend against self-disclosure (both about mental health, but also other person details). Disclosing personal information to a client could be viewed by colleagues/supervisors as unprofessional, could confuse the boundaries of the therapeutic relationship and in some cases might actually be harmful. I can’t quote the theory or research that says that this is the case, and there may well be times when it is seen as helpful (an interesting topic for research perhaps?), but I don’t think the university or the organisations I work within would support me to disclose in this way. I find many similarities between myself and my clients and I do draw on these in my work, though in less explicit ways. My mental health history isn’t the only thing clients don’t know about me, they also don’t know about my physical health, my relationships, really many things. This does set up an imbalance in the relationship, but a relationship between therapist and client is very different from others in their lives, and the boundaries are part of what makes it helpful. I am also entitled to privacy, my mental health history is only one part of me and I may choose to share it, but feel no need to ‘confess’ it to anyone.

    In addition to guidelines surrounding self-disclosure, I think it might be important to recognise quite how difficult it could be for a mental health professional to be open about their experiences. There are accounts of this, both in the media and in research (I just did a quick google, this article is a good example and has many comments from other professionals with personal experience http://www.time-to-change.org.uk/blog/mental-health-professionals-stigma, as is this one http://www.jrf.org.uk/sites/files/jrf/scr488.pdf ). The work can be very emotionally intense and I imagine many professionals fear being viewed as not sufficiently ‘stable’ to carry out this work, or having their motivation for working in the field questioned. From my own experiences, I remember being asked to fill out an occupational health form before I began training, which amongst other questions, asked if I’d ever taken an overdose or been hospitalised, with no indication of how this information would be used. I remember feeling very scared that my place on the course might depend on how I answered that form! I do draw on my own experiences, but it’s difficult to know to bring this into training. It’s a shame it wasn't possible to find someone to speak from this perspective in your research, it might be that a safer space is needed for people to feel comfortable to share their views.

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  9. As a Clinical Psychologist I and my colleagues know that we at times struggle too. Clients often verbalise the assumption that our lives are perfect, perhaps it's necessary part of the work the fantasy or reality that we are well enough to help, I would want that in my own mental health provider. Perhaps it provides a space for some to express anger at what's been directed at them from society, or from the self attack of people frustrated with their own difficulties. One to one therapy isn't a support group for people who share a common experience and as such it provides a different set of opportunities for exploration and development.

    I would not talk about my difficulties with my clients because they have't come to hear about me. I would choose not to talk about my difficulties with my colleagues because I value my privacy and value being seen as competent and able when at times this is at odds with how I feel inside.

    My silence about my position regarding my own mental wellbeing is not to maintain an "us and them" fantasy but is for the reasons stated above. I go into the therapy room humbled, even if clients and others assume my life is sorted.

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  10. Some really thoughtful points here and thanks to all who have weighed in so far. I'll re-tweet the post later today drawing attention to the quality of the discussion.

    Just to throw in my 2p worth I feel the idea of breaking down the barrier betweet the professional and user around common experience is an appealing one but (like Ally above) I do sometimes wonder how helpful it might be. I suppose I wonder if the experience is necessarily all that shared. In the end as a therapist I'm supposed to be there to validate, honour, think about, understand etc the experience of the person in the other chair.

    John McGowan

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  11. I am a clinical psychologist and suffered bad postnatal depression after my children were born. I have always bed open about this, with friends, colleagues and on occasion with clients, ragout I am very careful about the use of self disclosure in therapy. I wrote a blog about my journey to recovery. I found it empowering to be open, and not to have to feel embRrassed about it etc.

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    1. I'm curious Emma. I wonder why we have to feel embarrassed about such things? I'm not for a moment saying that the feeling is unreal or imagined or that there isn't the potential for shame there. Something I've been thinking about lately is a quite deep narrative we seem to have about mental health being bound up in moral failings. The persistence of this narrative I think is signalled by the need we have to repudiate it over and over again. Usually with a counter narrative of illness. I just wondered if you might have any thoughts on that. (John McGowan).

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  12. It is good to continue this debate. A few thoughts strike me. There are some notable examples of professionals - including clinical psychologists - who are very 'out' about their experiences / diagnoses etc. They do not seem to have been considered in the talk of 'barriers'. Also, I wonder where it leaves professionals who do not necessarily have experience of significant mental health difficulties when there is pressure to 'come out'. There is some talk at the moment of 'peer professionals', i.e. not peer support workers but professionals such as psychiatrists, psychologists etc. who explicitly state their experience. Something that seems to get lost in this is the individual experience and implicit messages (maybe just my reading) that professionals SHOULD come out or that something is stopping them when they COULD. The 'coming out' analogy is useful to a point. For some people it might be an important part of their outward identity, to be shared with people immediately. For others, this aspect of self might be much more personal and private. Equally, some service users and / or carers might find it useful to know about therapist / psychologist experiences while others may find it unnecessary or even intrusive in their own therapeutic time. The benefit of knowing about 'shared experience' is the assumption that there are commonalities, but one person's experience of a particular mental health difficulty might be very different to another's experience. Rather than being 'in' or 'out', why can't there be a careful negotiation around these issues between each individual therapist / psychologist and client? In my experience as a clinical psychologist, coming out as a cat owner to a client who owns cats has done far more to aid our rapport than I imagine any knowledge of my own mental health history would have done, which might have highlighted the differences between the client and myself. We need to be careful not to assume that not coming out is only related to fear and stigma. Sometimes it is related to a carefully considered choice about what may or may not be therapeutically useful, or simply personal choice to keep some aspects of self to the self.

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  13. Interesting and complex debate. I must say I find it curious that the Psychologist (above) called 'Pink' considers an admission that she has had her own therapy equivalent to a 'coming out' experience. There are many of us, myself included, who believe that having personal therapy is an essential ingredient in the training of anyone intending to practise psychotherapy. Sadly, it is not a requirement in the training of Clinical Psychologists in Britain and I believe the profession is worse off for that. I think it's extremely important for psychologists to explore their own vulnerabilities. To assume that you don't have any, is frankly ridiculous and potentially risky. The very least you can do for service-users is be willing to open yourself to some of the experiences that they might have had in the difficult process of sharing difficulties and intimacies with a professional.

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  14. Hi Angela,

    thank you for your comment. I agree 100% with what you've said about psychologists having their own therapy. Perhaps my first post wasn't clear, I was asking Laura to define a) what counts as a 'service user' (ie would my personal therapy count or does it have to be NHS, would me sitting with my own vulnerabilities and trauma count or do I have to have had a diagnosis) and b) what would coming out look like to her (does me telling colleagues/clients/everyone about my personal therapy count, or does she need me to write an article/set up a blog/website/be rufus may?). So I'm not sure if I've 'come out', or even if i have anything to 'come out' about, does that make my comment clearer?

    best wishes,

    Pink

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  15. I would like to just make one point: If you are suffering mental health difficulties you have rights under the disability discrimination act. You have the right not to be discriminated against on mental health grounds. You have the right to access to work. You should be treated with the same respect as anyone else.

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  16. It’s great to read the comments from everyone. It seems this is an issue that’s important to a lot of people. I’m all for choice in this area. Peoples' right to choose where and when they speak about private issues comes first. But in this case choice is circumscribed by peoples’ beliefs about the consequences of being open. Is there a belief that people with a mental health problem are somehow dodgy characters who may not be fit to practice in health and social care? Silence and lack of transparency leave false beliefs unchallenged and allow stigma and discrimination about people with a mental health problem to continue.
    No one should feel they have to hide a health problem in order to be able to work. It can't be good for the worker and so I suspect in the long run it isn’t good for service users either. Simply put I think we would all benefit if it were easier to talk about mental ill health.

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  17. I think there is a belief floating around about possible lack of fitness to practice, but as I understand it that debate has now been settled. You cannot be pronounced unfit to practice on the grounds of having a mental health diagnosis. Perhaps many people still think you can, and do not know that this has now been sorted. But it has. You can't. Full stop.

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  18. After having a fairly spectacular and public change from mental health educational professional to service user status ten years ago, I was initially very open about it and felt supported and somewhat liberated at being recognised as fallable. Colleagues wrote me letters and cards expressing there own struggles and sharing personal information with me which I felt put us all in the same boat. Ten years on, Im not sure such honesty has benefitted me in the long run. Firstly the culture has changed from progressive to results led and I feel that any weakness at all is considered a burden. I know colleagues who are even now on sick leave with 'the flu' or 'chronic fatigue syndrome' who I know are struggling with mental health issues. An organisation which I felt would be compassion isnt and people make the right noises if a colleague has cancer but 'stress' is just a word for malingering. There is also a recent phenomena of accusing mental health professionals who have mental health issues of jumping on the service user bandwagon for credibility. You really cant win.

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  19. I work as Laura Lea's counterpart on the Surrey PsychD programme. I am a current user of mental health services and have been back and forth with my views on this topic. I do see a lot of rage (and I do identify with feeling that rage) and hurt at the way that mental illness (I'm calling it that for the moment) have decimated my life - and, most importantly for me, my career. At one time, I was a high-flying PR consultant until the wheels came off. Now, many years down the line, my career is not what it was. Don't get me wrong, I am privileged to be a) working and b) working in a university. I have a number of service user friends who envy me for both a) and b). I am grateful to be able to work, to be employable, and to keep going in a pressurised academic environment (many thanks to my pressurised former PR career for help with that). I understand the anger that people like Peter Campbell feel - he refers to himself as a survivor/activist because of the damage he feels has been done to him by the psychiatric system. And it is a system. And it is powerful. It can give and it can withhold. All my life I have longed for love and acceptance, and there was a long time when the only love and acceptance I could obtain was from mental health services. I have had some fantastic help from mental health services and some that has, frankly, nearly killed me. Yes, I'm angry and I'm hurt. But I need to move on. Like many people writing here, I have been privileged to have been on the receiving end of excellent psychotherapy. But the vast majority of service users aren't able to take advantage of this - either their distress is so great that it's all they can do to get dressed in the morning or the side effects from their medication are so great that they cannot focus on much else, or they don't have the funds to pay for private therapy.

    It doesn't bother me whether my therapist has used mental health services or not, nor do I wish to know. What I do need to know, is that s/he has felt emotional pain. And experiencing emotional pain is part and parcel of being human. I wonder if what we should be training in the future is not clinical psychologists or psychiatrists but philosophers.

    It is the stigma surrounding mental illness (I'm calling it that again) that does the damage, not the experience of it. Any level of emotional breakdown - from a bout of sobbing to a full blown psychotic episode - can be viewed by those in the health and social care field as indicative of some sort of 'weakness' and raises the query of 'fitness to practise'. I wonder if the scary notion of 'fitness to practise' is dangled over people's heads (especially trainees, who seem to fear it most), as a macho hangover from the medical model days - the 100 hour shifts of the junior psychiatrist who just 'got on with it'.

    I believe that we service users must acknowledge the past damage, the rage and pain and learn to work so that things are different in the future. My own small input into training future clinical psychologists ensures that they qualify having heard the voice of the service user (and carer) and have learnt about real issues from real people.

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  20. This is a really interesting debate and one I am very passionate about. I have had some difficulties with my mental health in the past and was always very open and honest about it. I was always lucky that my honesty was mostly met with admiration and support. However, I now work in mental health after a dramatic change in career (driven in part by my experiences) and have had some very negative experiences of self-disclosure. I had a job offer retracted after I returned my occupational health form with my honest disclosure. I also had an offer withdrawn from a University for a Social Work MSc course following my disclosure. These 2 experiences have left me feeling ashamed and scared and as a result I am now very reluctant to 'declare' my past. This in turn makes me feel bad as it goes against my character and my passion - e.g. I'm not ashamed of my past difficulties and in fact I'm proud as it's made me who I am today. I truly hope that the comments above are a genuine reflection of the 'system' changing. I worry that there is an underground discrimination occurring now and despite everyone saying that it's OK to be honest, the bottom line is that the candidate who doesn't have any vulnerabilities would be offered the job as I might be just a bit too much of a risk.

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