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Vulnerable leadership

VOL. 8, NO. 3, 37–38
Vulnerable leadership
Louise Younie
Clinical Senior Lecturer, QMUL, London, UK
© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted
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CONTACT Louise Younie
At a medical humanities educator workshop, a few years
ago, we asked participants to bring an image or poem
that they resonated with from the ‘Out of Our Heads’
Images and words were shared with the group
along with why they had been selected. Towards the end
of our semi-circle was a senior clinician and an educa-
tor. His chosen image was one of a patient, sat in foetal
position on a waiting room chair (http://www.outofour- He had chosen
this image because it reminded him of the patients’ vul-
nerability. He paused. It reminded him also of his own
During the coee break a fth-year medical student
shared with me how his words had been the most useful
utterance she had heard for months, having just com-
pleted her nals. I probed a little deeper. She told me
of student stress and bravado. To hear someone further
down the line able to talk about his own vulnerability
was, to her, like a breath of fresh air.
I have pondered this anecdote for a number of years
in the context of medical education and medical prac-
tice, and more recently in the light of my own dance
with death through cancer. Why is it, I wonder, that we
so rarely share our experiences of vulnerability either as
students or qualied health professionals? I know from
my own experiences that vulnerability and being a
patient go hand in hand. As a patient there is little choice,
but to embrace our fragile state when our mortal body
has been assailed by some kind of pestilence. But for the
healthy doctor who wields power in the lives of those
struck by disease, vulnerability can be and often is held
at arm’s length. Research suggests, however, that feelings
of professional uncertainty do abound especially for stu-
dents and young doctors in emotionally laden situations.
[1] So it may be that we feel vulnerable but do not share
or talk about it. A student writes about sitting in a breast
cancer clinic and in one day hearing three people receive
a diagnosis of breast cancer, the youngest being just a
couple of years older than herself:
We were discussing how it is almost taboo to show
emotion about things like this, not only on the wards
but also when chatting afterwards to other students.
There is an unwritten rule that you have to prove …
that you can cope with hearing/having to give bad
news and be absolutely ne with it. That’s the mark of a
good doctor- leaving it all in the hospital.[2]
Anatole Broyard [3], a writer who died of prostate
cancer disagrees. He invites the doctor to ‘let the sick
man into his heart’, to share ‘the wonder, terror and
Why this matters to me
Vulnerability is often considered a weakness and something to avoid especially within the competitive medical
culture, yet my belief and experience is to the contrary. It seems to me those in leadership who can engage
with their own vulnerability are potentially exercising great strength and courage as well as bringing relief and
release for others looking up to them. Also in engagement with patients, being able to touch our own vulnera-
bility allows us to draw closer to those forced into vulnerable situations through situations beyond their control.
Key message
This paper challenges the notion of the powerful doctor and vulnerable patient, instead highlighting the gift
of our shared vulnerability and humanity.
and be ‘strong’, the strength of sharing vulnerable spaces
may be one of the most generous things we can oer our
peers, students or patients.
1. Creative reective work is
collated from medical students predominantly at the
University of Bristol. There is also sta and patient
contributions on this website.
Disclosure statement
No conicts of interest.
Louise Younie 
[1] Schei E. Doctoring as leadership, the power to heal.
Perspectives in Biology and Medicine. 2006;49:393–406.
[2] Younie L. A reexive journey through arts-based
inquiry in medical education [EdD Dissertation]. Bristol:
University of Bristol; 2011.
[3] Broyard A. Intoxicated by my illness. New York (NY):
Ballantine Books; 1992.
[4] Brown B. Daring greatly: how the courage to be
vulnerable transforms the way we live, love, parent, and
lead. New York (NY): Gotham Books; 2012.
[5] Executive Coaching Network. Leadership eectiveness:
great leaders balance strength with vulnerability.
[cited 2016 Jan 12]. Available from: http://www.ectiveness-great-
[6] Seppälä E. What bosses gain by being vulnerable. [cited
2016 Jan 12]. Available from:
[7] Nouwen HJM. Out of solitude: three meditations on the
Christian life. 2nd ed. Notre Dame (IN): Ave Maria Press;
exaltation of being on the edge of being’. That is where
our shared humanity lies. When doctors distance
themselves and batten down the hatches they may
never get beyond their own shores of understanding,
and their patients are left to voyage the seas unac-
companied and alone. Brene Brown [4] is a researcher
and storyteller who has written a great deal in the
field of vulnerability. She postulates that allowing
ourselves to be seen and known, that is, making our-
selves vulnerable, allows us to connect in meaningful
ways with others. A leadership website explores the
balance of strength and vulnerability and how shared
vulnerability can lead to inclusiveness, teamwork and
enhanced credibility.[5] Vulnerability in the context of
leadership, says another site, ‘implies the courage to
be yourself’, ‘replacing professional distance … with
uncertainty, risk and emotional exposure.[6] These
ideas could apply equally well to interactions with
patients or peers.
My colleague at the educational workshop who
shared the vulnerability that he can feel as a doctor ies
in the face of the prevailing medical culture. His words
worked to build community and connection. He shows
his soft underbelly, strong and courageous enough to
leave himself exposed and open to attack. Henri Nouwen
[7], a Christian mystic, oers a perspective of vulnerability
as strength and a gift.
When we honestly ask ourselves which person in our
lives mean the most to us, we often nd that it is those
who, instead of giving advice, solutions, or cures, have
chosen rather to share our pain and touch our wounds
with a warm and tender hand. The friend who can be
silent with us in a moment of despair or confusion, who
can stay with us in an hour of grief and bereavement,
who can tolerate not knowing, not curing, not healing
and face with us the reality of our powerlessness, that is
a friend who cares.
We could change the word ‘friend’ above, for ‘doctor, and
although we are often called upon to give advice, to lead
... The kind of vulnerability she is talking about is that of taking risks, sharing something of ourselves, opening the door to our inner worlds and we can do this as well with our patients as with our students. I have written elsewhere about 'vulnerable leadership' and how 'the sharing of vulnerable spaces may be one of the most generous things we can offer our peers, students or patients' (Younie 2016). ...
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We are made out of the same stuff as human beings and have the same longings and fears. As health care professionals/students, are we better off suppressing our weaknesses and fears or sharing them? If the answer is sharing them, then how best might we allow this shadow work to happen? My experience with medical students suggests that creative enquiry offers a valuable space for this counter-cultural work within medical education. Martha Fineman (2015) writes that for us as human beings, the inevitability of vulnerability means that there is no position of invulnerability; there is only the possibility of resilience. Yet for the medical student or health professional any lived experience of vulnerability is rarely shared. This may not be strange given the competitive macho culture they find themselves in (Jennings 2009). Doctors' memoirs frequently reveal how students and junior doctors receive 'direct or indirect messages to be physically and emotionally tough' (Poirier 2006:546). Research suggests however, that medical student distress is rife, with high levels of anxiety or depression and risk of burnout (Dunn, Iglewicz, and Moutier 2008, Dyrbye, Thomas, and Shanafelt 2005). In this context how might we facilitate medical student development of resilience or inner strength which moves beyond just a tough exterior apparently able to weather the knocks? Clearly, the reasons behind the suffering of our medical students are multiple and complex and stretch far beyond medical student and institutional cultures of competition and heroism. Other situational factors include workload, patient suffering and finances as well as personal factors such as life events, coping strategies and personality (Dyrbye, Thomas, and Shanafelt 2005). To date more is known about factors leading to medical student distress than how to begin to address these (Dyrbye, Thomas, and Shanafelt 2005, Perrella 2017). Teodorczuk et al (2017) suggest the current medical education literature points to resilience as the new panacea to address our 'burnout epidemic'. But resilience, if it is about the individual being able to remain positive and bounce back in the face of adversity (Teodorczuk et al. 2017), risks being just one more competence to be mastered. From this position, the suffering medical student has to implement strategies to manage their struggles or find themselves also failing at being resilient. Indeed, Maslach et al (2001) report that individually focussed anti-burnout programs e.g. stress management workshops have only
... A vulnerable leadership (29) approach is taken whereby the facilitator presences themselves as human in the room. Students are invited to articulate group rules -such as confidentiality and respect, and to consider their boundaries and how much they choose to share, given the potential for the creative process to open up inner doors to unexpected depths. ...
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Whilst the biomedical curriculum in medical education potentially distances future doctors from their patients and their own humanity and suffering, creative enquiry (exploring lived experience through the arts) can be a humanising force. The arts invite connection with ourselves and the other through, for example slowing down perception, facilitating emotional expression, reframing experiences, inviting multiple perspectives and offering participatory and improvisational engagement with materials. Through case studies in medical education, this chapter explores how creative enquiry facilitates connection, solidarity and has the potential to engender human flourishing.
... Workplaces that embrace the concept of "confident vulnerability" promote the capacity to compassionately accept and "own" one's own strengths and vulnerabilities. Rather than striving for autonomy, this approach advocates a leadership style that promotes working to one's personal strengths while openly recognizing and seeking help from others in areas of shortfall/vulnerability-thus achieving a healthy balance between autonomy, interconnectedness, and mutual support (Brown, 2012;Younie, 2016). This concept counters the current cultural overvaluation of "Unrelenting Standards," whereby an excessively high value is placed on self-sufficiency, overachievement and workaholism. ...
Recent studies highlight a range of factors that place psychotherapists at risk of burnout. The aim of this study was to investigate the ethics issues linked to burnout among psychotherapists and to describe potentially effective ways of reducing vulnerability and preventing collateral damage. A purposive critical review of the literature was conducted to inform a narrative analysis. Differing burnout presentations elicit a wide range of ethics issues. High rates of burnout in the sector suggest systemic factors and the need for an ethics review of standard workplace practice. Burnout costs employers and taxpayers billions of dollars annually in heightened presenteeism and absenteeism. At a personal level, burnout has been linked to poorer physical and mental health outcomes for psychotherapists. Burnout has also been shown to interfere with clinical effectiveness and even contribute to misconduct. Hence, the ethical impact of burnout extends to our duty of care to clients and responsibilities to employers. A range of occupational and personal variables have been identified as vulnerability factors. A new 5-P model of prevention is proposed, which combines systemic and individually tailored responses as a means of offering the greatest potential for effective prevention, identification, and remediation. In addition to the significant economic impact and the impact on personal well-being, burnout in psychotherapists has the potential to directly and indirectly affect client care and standards of professional practice. Attending to the ethical risks associated with burnout is a priority for the profession, for service managers, and for each individual psychotherapist. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... Importantly, at a systemic level, given the role of the emotional inhibition EMS and detached protector coping mode (i.e., numbing emotions and distancing others) as predictors of EE, measures should be taken to minimize isolation at work and encourage supportive professional relationships, supervision, peer consultation groups, opportunities for informal support, and mentoring relationships (Skovholt, 2001). In order to address the dominant work culture that overvalues detachment and intellectualization at the expense of emotional connection and support, it will be important in the future to strive to cultivate work cultures that value self-expression, openness, authenticity, vulnerability, and interpersonal connectedness (Brown, 2012;Younie, 2016;Zijlstra, Cropley, & Rydstedt, 2014). In addition, promoting a culture of creativity, play, and spontaneity can provide a balance to the heaviness of work duties and responsibilities (Baker, 2003;Skovholt, 2001). ...
Psychologists are subject to multiple competing emotional demands that increase the risk of burnout. Research has demonstrated that burnout arises from both organizational and personal factors, including psychologists' personal beliefs and coping. Preliminary research indicates that Early Maladaptive Schemas (EMS) are associated with high burnout, yet, to date, the role of EMS and associated coping responses (Maladaptive Coping Modes [MCM]) in predicting high burnout among psychologists has not been investigated. Four hundred and forty‐three psychologists completed a self‐report online questionnaire comprising the Maslach Burnout Inventory—Emotional Exhaustion Scale (EE), Young Schema Questionnaire (YSQ), and Schema Mode Inventory (SMI). The two most common EMS amongst psychologists were Unrelenting Standards and Self Sacrifice. There was substantial indication of burnout, with 18.3% in the high range and 29.6% in the moderate range of EE. The most common MCM were Detached Protector and Detached Self‐Soother. Controlling for demographics and job demands, EMS accounted for an additional 18% variance in EE. MCM accounted for an additional 6% beyond the variance explained by demographics, job demands and EMS. Practical recommendations are suggested to reduce psychologist burnout.
... GPs have anxieties like everyone else -about making mistakes, about hitting targets, about complaints, about the complexity of modern-day general practice, about careers and appraisals and families … Louise Younie describes how, when leading a medical humanities workshop, she invited participants to describe an image or poem that resonated with them. [8] One senior clinician chose the image of a vulnerable person -because it reminded him of his own vulnerability. This led Younie to realise that being prepared to show vulnerability can be a strength. ...
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Objectives: The objective of the study is the development of a virtual pilot of student and clinician creative enquiry during the COVID-19 pandemic lockdown. Methods: Evaluation of the pilot was carried out by a student-staff team and included review of creative pieces submitted, their impact and team reflection, drawing on the differing perspectives of staff and students. Results: A series of powerful creative enquiry texts have been published and presented from this pilot. Evaluation suggests individual and group flourishing are possible through creative expression and dialogue. Coproduction allows development of innovative and complex virtual educational spaces. Conclusion: Creative enquiry enables working across hierarchies, disciplines, and the virtual realm to build connection, relationship, and solidarity. Work is needed to create psychological safety and to support wider student engagement.
Background Concepts such as racism, oppression and social justice are critical curricular inclusions in nursing education. However, traditional approaches to nursing education often fail to produce the desired reflection and change amongst students. There is an urgent need to develop nursing educators that can step outside the rigidity of the curricular status quo and engage students with pedagogies that support critical reflection, analysis and action. Participatory, experiential and interactive theatrical methods rooted in critical pedagogy, such as Theatre of the Oppressed (TO) and Forum Theatre (FT) may prove more effective at engendering reflection, analysis and action. Objectives The study explores health care providers' (including nurses, nurse educators and allied health professionals) and nursing students' experiences, reflections and usefulness of TO and FT as nursing pedagogies. Design Influenced by Freire's Pedagogy of the Oppressed and Boal's Theatre of the Oppressed, this study was conducted on a Western Canadian university campus. Two groups participated. one that included health care providers (HCP) (n = 8) and the second that included an audience of nursing educators and students (n = 7). HCPs participated in a two-day TO workshop, while nursing students participated as audience members in the FT performance. The data were drawn from sharing circles and group discussions and were analyzed using thematic analysis. Results The findings from HCPs revealed that TO represents an opportunity for reflection and growth; strengthening relationships; and practicing vulnerability. Given that students only participated as audience members, they described practical applications for using TO and FT as pedagogies in nursing education including in simulation and in theory-based courses. Conclusion This study demonstrates that TO and FT can play an important role in supporting HCPs' development as critical educators through embodied and reflective practice and that nursing students endorse the application of TO and FT in a broad range of learning contexts.
Background: Physician mental health is an increasingly discussed topic. Despite the progress made regarding the discussion of physician mental health, these issues remain concerning. In particular, the discussion as to why these issues are so problematic remains limited. Contributors can include bullying, the "hidden curriculum" of medicine, how the medical culture handles errors, and importantly, shame. Objective: This narrative review evaluates the literature on bullying and abuse in medicine, how abuse can exacerbate shame, how the handling of medical errors can exacerbate shame, how shame can negatively affect mental health, and how the medical community and leaders can mitigate these issues. Discussion: Physician mental health remains an important issue. Job-related stressors, bullying, medicine's hidden curriculum, medical error, traumatic patient encounters, and perfectionism can contribute to physician depression and burnout. Shame may underlie these factors. Shame is a universal emotion that leads to poor self-esteem, depression, eating disorders, abuse, and addiction. However, shame can be addressed and overcome, especially via acknowledgment, vulnerability, and empathy. The medical community can provide some of these techniques by encouraging environments of kindness and respect, giving constructive rather than destructive feedback, providing empathy and support after a medical error, and encouraging mutual learning environments where questions are asked with respect in order to enhance learning. This is opposed to hierarchies and "pimping," where questions are asked with intimidation and disrespect. Conclusions: Shame is likely a contributor to physician mental health issues. For shame resilience to occur, it must not be kept secret and mutual support should be provided. By addressing the possible causes behind physician mental health concerns, including shame, more solutions can be proposed.
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Physician power has been attacked, and tabooed, in legitimate efforts to strengthen patients' rights. Yet the structural and symbolic power wielded by doctors is what makes good and right healing actions possible. Avoiding the power issue contributes to a confusing state, where patient trust is faltering and physicians are uncertain about how to fulfill the doctor's role with the intellectual tools of mere science and technology. I argue that constitutive characteristics of health, illness, and the clinical encounter necessitate a prescriptive and responsible healing agent who is more than a technocrat, an information broker, or a seller. The article proposes clinical leadership as a concept offering practical and ethical direction to clinicians, education, research, and health policy. Leadership presupposes reflective awareness of physicians' structural and symbolic power, and is displayed as discerning, empowering improvisations in critical situations, based on empathy and willingness to learn from patients. The notion of clinical leadership highlights patient vulnerability, medicine's ethical core, and the importance of character development in medical education.
A reflexive journey through arts-based inquiry in medical education
  • L Younie
Younie L. A reflexive journey through arts-based inquiry in medical education [EdD Dissertation]. Bristol: university of Bristol; 2011.
What bosses gain by being vulnerable
  • E Seppälä
Seppälä E. What bosses gain by being vulnerable. [cited 2016
Out of solitude: three meditations on the Christian life
  • Hjm Nouwen
Nouwen HJM. Out of solitude: three meditations on the Christian life. 2nd ed. Notre Dame (IN): Ave Maria Press; 2004.
Intoxicated by my illness
  • A Broyard
Broyard A. Intoxicated by my illness. New York (NY): Ballantine Books; 1992.