CHAPTER 91 Coping with the Rigors of Psychiatric Practice*
OVERVIEW
The practice of medicine is focused on disease, not health, and on treatment, not primary prevention. Therefore, it should not be surprising that physicians have difficulty minimizing their own stress and preventing burnout in their own lives. Throughout medicine (and especially in psychiatry), clinicians confront suffering and despair more often than they see success and happiness. In addition, the very same character traits that make physicians successful (i.e., perfectionism, an exaggerated sense of responsibility, and selflessness) also make physicians vulnerable to stress. Stress can be defined as the condition that occurs in response to adverse external influences, which is capable of affecting both physical and psychological health. The daily stress of practicing medicine, when left unaddressed or unmanaged, can progress over time to burnout. Burnout is a pathological syndrome in which prolonged occupational stress leads to emotional and physical depletion, and ultimately to the development of maladaptive behaviors (e.g., cynicism, depersonalization, hostility, and detachment). Understanding the root causes of stress and burnout, exploring ways to reduce vulnerability to burnout, and learning skills to cope with the stresses inherent in psychiatric practice are important factors in building and maintaining a successful career and establishing a fulfilling life.
EPIDEMIOLOGY
Despite their academic, vocational, and societal success, physicians are immune to neither disease nor suffering. In fact, one can argue that physicians are more likely to experience emotional distress, given the nature of their work; studies that have identified high rates of suicide among physicians support this idea. While physicians, as a group, have lower mortality rates from several diseases (e.g., chronic obstructive pulmonary disease and liver disease), they have a higher rate of suicide than do other professionals and members of the general population1 (Figure 91-1); for male physicians, the relative risk ranges from 1.1 to 3.4, and for female physicians, the relative risk ranges from 2.5 to 5.7.2 In the general population, the suicide rate is four times higher for men than it is for women; in physicians, the rate of suicide for women is equal to that of men.3 Up to 12% of physicians report an increased use of substances during residency4; psychiatrists have particularly high rates of substance abuse compared to those in other medical specialties.
ETIOLOGIES FOR STRESS AND BURNOUT
The practice of medicine in today’s society is both challenging and rewarding; however, it is also stressful and not without the potential for burnout. Several aspects of psychiatric practice leave the psychiatrist especially vulnerable to stress and, ultimately, to burnout (Figure 91-2).
Frequent Encounters with Distress
Psychiatrists encounter human suffering on a daily basis. The nature of psychiatric practice is that clinicians witness countless stories of sadness, anger, and betrayal. While moments of joy and happiness can arise, they often seem few and far between. The chronic and devastating nature of many psychiatric diseases increases the emotional burden on the clinician. Since psychiatrists must remain emotionally available to their patients to experience and to express the empathy that is necessary for the formation of an alliance, this emotional availability makes psychiatrists particularly vulnerable to suffering alongside their patients (even though they must consistently maintain enough distance to remain objective). Therefore, a critical balance must be maintained and a precise emotional distance preserved.
Ethical Dilemmas
The patient’s reliance on the psychiatrist for guidance can raise a host of ethical conflicts. Psychiatrists may find themselves in the position of watching their patients make unwise, and even dangerous, decisions, and being unable to curtail this destructive behavior. Psychiatrists may have to enforce mandated treatment regimens, to hospitalize patients against their will, or even to physically or chemically restrain violent patients. There may even be times when a psychiatrist must intentionally break a patient’s confidentiality for his or her safety, or for the safety of another. None of these decisions is made lightly, and each requires a great deal of reflection and emotional energy.
Transference and Countertransference
The daily practice of psychiatry is filled by issues of transference and countertransference, which can lead to the development of intense emotions in the patient and in the clinician. Furthermore, several psychiatric illnesses have, as core symptoms, difficulty with interpersonal interactions. Afflicted patients, including those with borderline personality disorder and narcissistic personality disorder, can pose a special challenge to the psychiatrist. One critical facet of the treatment may be to work through the patient’s hostile, aggressive, or devaluing transferences; this process is often extremely difficult for the psychiatrist. This difficulty may be further compounded if the psychiatrist cares for many such patients or if the negative transference is particularly long-lived. In addition, psychiatrists, through the course of listening to, and empathizing with, their patients, may also become the object of loving feelings or dependent attachments. Coping with intense transference, while monitoring one’s own countertransference, can be exhausting; it is a daily challenge for most psychiatrists.
The Perception of Failure
Psychiatrists treat chronic illnesses, which are subject to relapse, and which carry significant morbidity and mortality risks; thus, the very nature of psychiatric disease can lead the psychiatrist to experience feelings of failure as a doctor and as a healer. Despite knowledge of treatment-response rates, psychiatrists may ponder the notion that if they could only find the right medication or say the right words in therapy, the patient would be healed. Failure to respond to treatment can be, and frequently is, viewed as a failure of both the medical intervention and the treater. The fact remains that, due to the nature of psychiatric disease, not every patient will be healed; the psychiatrist then may experience feelings of failure.
Controlling Affect
Despite the intensely emotional nature of psychiatric work, psychiatrists must consistently control their affect to do their jobs well. When patients are overwhelmed by sadness, despair, anger, or frustration, psychiatrists must keep their own reactions in check, sometimes bottled deep within. While this control of affect is necessary for the practice of psychiatry, it can ultimately lead to the denial of emotions. If one denies the existence of affect (even after the patient has left the office), it can lead to increased stress and to vulnerability to burnout. Instead, informal debriefings with colleagues, or formal supervision, may encourage the necessary expression of what is controlled during patient sessions.
Responsibility and Uncertainty
The practice of psychiatry is multidimensional and it incorporates interpersonal and individual dynamics, sociology, biology, and pharmacology. The complex nature of psychiatry makes it an exhilarating, yet uncertain field. Psychiatrists must often base clinical decisions on biased, incomplete, or ambiguous data. While the breadth and depth of psychiatric research are growing exponentially, there is still a dearth of research to guide many clinical decisions. These challenges are further compounded by the added stress of answering to institutions, to insurers, to patients, and to their families. Health insurance organizations often establish standards of care without psychiatrist involvement; this can undermine the pride and self-determination of practitioners. Psychiatrists may find themselves in the difficult position of not being able to provide the treatment they believe is best; instead they may offer assistance based on an insurance company policy.
Disruption of Social Relationships
Psychiatrists frequently work in isolation; this leaves them alone to face the effect of psychopathology and disease. Furthermore, rules regarding confidentiality inhibit sharing the details of one’s day with family and friends. Social engagements and family time can be interrupted (without warning) by emergencies. These factors can fracture social relationships, decrease social support, and increase the risk of burnout. Furthermore, vocational burnout is, in turn, associated with low satisfaction in relationships (with patients and with clinical staff).
Delayed Gratification
The ability to delay gratification is an important developmental milestone. The practice of medicine raises it to an art form. In order to successfully complete 4 years of medical school, 1 sleep-deprived year of internship and 3 grueling years of residency, physicians must be adept at delaying gratification. But this skill, when taken to an extreme, can lead to burnout. Physicians may be tempted to put personal, non–work-related goals on hold, in the service of career success (e.g., “I can’t get married, have children, or buy a house until I finish residency, have a stable practice, or have enough money in the bank.”). Such rationalizations can be extended indefinitely and may lead to a life lacking balance and devoid of nonvocational success.
Being the Caregiver
Psychiatrists, in general, have a strong need to be needed and to care for others. These traits are part of what initially draws clinicians to the practice of psychiatry. At the same time, the dependence some patients develop on their psychiatrist can be overwhelming in its intensity. Furthermore, focusing intently on the needs of others can lead to denial of one’s own need to be cared for.
Financial Stress
While the popular perception is that all doctors make copious amounts of money, the reality is quite different. The cost of medical education can be astronomical and it continues to rise each year; however, the salaries of many physicians do not enjoy the same growth, and the increases in earnings over time may not even match the rate of inflation. Many young doctors finish residency with enormous debt, and with limited options for repayment and deferment of loans. Furthermore, the practical options for improving one’s financial situation are limited to working longer hours or seeing more patients (for shorter periods of time). Either option is likely to increase, rather than to decrease, vocational stress. This pressure may be especially intense for early career physicians.
SPECIAL SITUATIONS IN PSYCHIATRY
Coping with Patient Suicide
A Profound and Enduring Effect
Half of all psychiatrists have had one (or more) of their patients commit suicide5,6; approximately one-third of those psychiatrists experienced such a loss while they were still in residency training.5 Furthermore, one-quarter of psychiatrists who had experienced patient suicide stated that it had “a profound and enduring effect” on them throughout their careers.5 While the practice of most medical specialties entails dealing with death, suicide in the practice of psychiatry takes on additional meaning. Since one of the primary tools in psychiatry is the individual, when the treatment fails, it can feel as if the treater has failed. Furthermore, while death from cancer can be seen as inevitable, death from suicide can be viewed as a choice.7
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