|Year : 2008 | Volume
| Issue : 2 | Page : 70-74
Burden of being a psychiatrist - professional stress
Consultant Psychiatrist, 250, 43rd Cross, 9th Main, 5th Block, Jayanagar, Bangalore-560 041, India
Consultant Psychiatrist, 250, 43rd Cross, 9th Main, 5th Block, Jayanagar, Bangalore-560 041
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Psychiatrists suffer professional stress. This is being studied for about four decades in the West, but not in India. The reported etiological factors are related to the nature of the profession and clinical situations, characteristics of the psychiatrist, and of the patient. But, there are many unanswered questions. This article briefly overviews the topic, poses few questions, and suggests certain remedial paradigms. The theme of this article applies equally well to mental health profession in general.
Keywords: Burn-out, ideal behavior, professional stress
|How to cite this article:|
Shamasundar C. Burden of being a psychiatrist - professional stress. Indian J Psychol Med 2008;30:70-4
| Introduction|| |
Even though Spiegel  wrote about psychiatry being a high-risk profession in 1975, only recently do we see few reports of studies appearing now and then in professional literature, in the West and far East, and that too mostly in relation to elderly and terminally ill.
Reflecting retrospectively, I become aware that I have been having my share of professional stress in varying degrees almost regularly. Yet, I have not taken serious note of this fact in spite of me presenting a paper on it about 25-years ago in a local academic meeting. I became acutely aware of this fact after my retirement from active service 12-years ago, which prompted me to give this issue some publicity as it has not enjoyed the attention, interest, and importance it deserves.
In this paper, I have attempted to:
- Briefly overview the topic.
- Pose a few questions to fill-up gaps in our knowledge.
- Propose culturally rooted paradigm for management.
- Voice my own viewpoints wherever appropriate.
We are all aware of most of the issues relating to this topic. This article is only meant to serve as a 'wake-up call' for the profession to start addressing these issues urgently and seriously. Even though this article addresses psychiatric profession, its contents are applicable to all healing professions, especially those who function as psychosocial counselors.
| Phenomenon of Professional Stress|| |
In 1960s and 70s, psychiatrists were only next to anesthetists in highest suicidal rate, most probably causally related to the profession.
According to a few studies doctors experience high level of stress leading to psychosomatic harm and burnout. , One study surveyed 212 doctors and nurses, of whom 83% responded. Twenty seven percent of them qualified as 'probable psychiatric cases'. Primarily being doctors, psychiatrists seem to be vulnerable to these consequences.
After reviewing 23 studies on the topic,  I conclude that psychiatry is indeed a stressful profession. Three decades ago, McCartley observed that psychotherapists responded to stress with depressive feelings. Kumar et al .  found that nearly 33% of New Zealand psychiatrists experienced moderate to high levels of emotional exhaustion. This emotional exhaustion is one of the features of burnout. The other two features are depersonalization with negative interpersonal feelings, and lack of feeling of accomplishment.
Medical, especially mental health, profession is considered a 'noble profession'. Ancient Indian wisdom proclaims that "comforting, counseling, and easing a fellow human's distress is the noblest service and highest virtue." Yet, paradoxically, our profession seems more vulnerable to stress. This paradox needs to be studied and explained. Transient response to stress with recovery over time is natural. In extreme stress, I believe that the recovery will be similar to 'oxygen-debt' or 'sleep-debt'. But, depending upon the clinical circumstances, vulnerability, and coping skills, there can be residual effects, which may cumulatively buildup to burnout.
Source of stress or burden in our profession is the result of interaction between various factors, no single factor alone being responsible. And, there are no clear boundaries between causal factors. Kumar et al  have listed predisposing, precipitating, and perpetuating factors as causative. Other writers have listed factors attributable to the profession and clinical situations, to the professional (psychiatrist), and to the patient. I prefer the latter grouping of causal factors.
| Causal Factors Attributable to the Profession and Clinical Situations|| |
Sahraian et al .  found that nurses experienced higher levels of burnout in psychiatric wards compared to medical, surgical, and burns wards, as if interaction with psychiatric patients is stressful. It is probably so. For example, Guthrie et al .  have said that psychiatrists interact more intensely with their patients. As a consequence, they are not only exposed to more intense emotions,  but also to emotionally more difficult situations.  Besides, psychiatrists also bear the responsibility as instruments of change.
Empathy is an inevitable component of clinical and therapeutic interaction. Empathy involves enmeshment of psychic fields of interacting individuals resulting in bidirectional transfer of psychic contents.  Thus, apart from intended transfer of information, 'automatic' transfer of positive and negative moods and feelings also take place, including patient's distress. Empathy is a 'double-edged sword'. Empathy also contributes to 'transference and counter-transference' reactions, which can be stressful in their own right. Of course, the psychiatrist's personality, coping skills, and other variables influence how effectively the clinician deals with these consequences.
Psychiatric clinical work often involves ethical dilemmas. For example:
- Work environment may be inimical to ethical practice.
- One may encounter mental illness or drug-abuse in a colleague.
- One's patient may be a bus driver who suffers drug or alcohol abuse. 
- Lepping  observed that psychiatry is the only specialty that uses legislation to protect patient's rights, and this legislation often restricts or interferes with psychiatrist's autonomous clinical decisions. In addition, there is an inappropriate expectation imposed on psychiatry for some kind of 'social policing'.
- Spiegel  pointed out that certain degree of uncertainty inherent in clinical decisions can also be a source of stress. The basic reason for this uncertainty is the Guassian distribution of all natural phenomena. In addition, all medical knowledge, especially psychosocial, is statistical in nature with only degrees of probabilities. There is always a risk of unexpected event or outcome. And, our classification system does not adequately reflect reality.
Ethics of psychotherapy requires the therapist to refrain from becoming: (1) influenced by moral judgments, (2) a part of family or marital dynamics, or (3) carried away by pathological dependency expectations of patient, thus denying him/her the decisional autonomy. The clinician may have to exercise conscious effort to observe these principles. Such an effort can be a source of stress.
| Causal Factors Attributable to the Psychiatrist|| |
Krenek et al .  studied the psychopathology in families of origin of 114 psychologists, 67 psychiatrists, and 85 general practitioners. Those who chose mental health as a career were close to a family member who had psychopathology and this choice also correlated with the quality of empathy.
Studies by two different teams, , independently found similar results that a professional's neuroticism score correlated with burnout. The latter team also reported that the professional's personality factors influence the outcome of stress, implying that the coping skills probably influence the outcome.
Are psychiatrists predisposed to suffer professional stress and its consequences?
| Causal Factors Attributable to Patient and Family|| |
Bongar  et al . audio-recorded structured interviews with 25 psychiatrists. The audio-records were then transcripted and independently reviewed and assessed by two senior psychiatrists. Eighty four percent of the respondents dreaded encounters with those patients they considered as 'difficult patients'. This difficulty was not related to transference or counter-transference issues. It means that interaction with certain patients is very stressful.
It is common knowledge that clinical work with patients with personality disorders, or chronic 'poor-prognosis' conditions is very stressful. Similarly, those occasions where the patient's pathology extends into family environment with or without symbiosis are also equally stressful.
| A Challenge to the Concept of Professional Stress|| |
Amos  quotes his professor saying that "there is no such thing as stress." I feel that the word 'stress' is used here in a sense of effect. Even though professional stress is real, I believe this challenge to be valid. I restate the challenge as, "professional stress need not have been there." I will try to explain how and why.
Let us consider a few real life examples that most of us are familiar with:
- A person toils over a few days conducting his daughter's marriage.
- Another struggles hard for a sports medal or a rank in the examination.
- Yet another completes a fortnight's trekking expedition in the Himalayas.
- An artist or a scientist toils for 16-18 hours a day over many days on one's cherished project.
Though physically and mentally tired, do the above individuals consider themselves as stressed? They may or they may not. Do they suffer psychopathology as a sequel? Most probably not. The message that I am attempting to project as a hypothesis is, "One does not generally suffer long-term psychopathological effects on account of doing what one loves doing, or cherishes as a goal or duty."
If we assume the above hypothesis as probably true, a natural question is, "are we psychiatrists in 'love' with our professional work? Or, or we deficient in terms of either interest, or some of the required abilities?"
What personality variables correlate with vulnerability or resistance to professional stress?
Are the above personality variables same as coping skills? If so, what coping skills correlate with vulnerability and resilience?
If we assume that stress management skills are equally effective in personal life as well as professional role: do effects of stress in personal life influence those in professional role and vice-versa?
Does degree of stress experienced at work correlate with degree of burden perceived by his or her family?
This query concerns the current trend of psychiatric clinical practice that has become overdependent on physical, medicinal, and behavioral modalities of management. It also concerns those colleagues who move over from clinical to academic and research activities. The question is, does such a shift in orientation represent an unconscious and rationalized consequence of burnout, or fear of burnout, or a substitute for burdensome psychotherapy?
| What Requires to be Done|| |
1. Initiate basic research in order to acquire some preliminary data, like:
- Phenomenology of professional stress and its manifestations.
- Extent of the problem.
- Etiological factors.
- Professional's personality profile vs. the effect of stress on self, clinical functioning, and family.
It is essential that professional bodies like Indian Psychiatric Society and Indian Association of Private Psychiatrists, jointly or independently, form 'study-groups' and raise research funds. The professional bodies would also do well to establish a commonly agreed upon convention that postgraduate teaching institutes will encourage its postgraduates to take up research projects in this area as a part of their thesis work. Periodic seminars and symposia on the topic will help to integrate the research data and provide new directions.
2. Implement measures of management already recommended in the literature
- Start and operate regular 'staff-support-groups', for example, like 'Balint-groups' as recommended by Fothergill et al ., Benson et al ., and Amos. ,, These types of activities are easier to be started at teaching institutions and where professional bodies are regularly active.
- Organize and conduct periodic 'stress-management' workshops as recommended by Amos. 
- Encourage professionals to develop and pursue outside interests and hobbies as recommended by Fothergill et al . 
| Additional Considerations|| |
Our cultural heritage advises neither to sell or trade - worldly or spiritual knowledge - nor offer help to the distressed. But, in contrast, our current social values permit trading the above as ''services',' often to the extent of exploitation. For example, in the erstwhile Mysore state in 1920s and 30s, applicants for medical college seats were often less than capacity, the motivation to apply being either interest on medicine, or wish to serve. In 1950s, when I joined the medical college, the number of applicants were 30-70% higher than the capacity, motivation to join being prestige and money. We are all aware of the current 'mad-rush' and high price for a medical seat, and the motivation is obvious. In such a situation, we have become unwitting partners in this system of market economy, which promotes, propagates, and sells a delusional goal of "symptom-free and suffering-free easy-life".
As a result of the above, have we become dissonant? Dissonant in terms of:
- The ideal (what one cherishes) vs. the actual (what one does).
- Cultural values vs. environmental constraints.
- Aspirations vs. abilities.
And, dissonance correlates with psychological morbidity. According to Mikulincer  dissonance probably functions as stress.
| A Dilemma|| |
Our ancient wisdom declares, and every one of us have personally experienced, that stresses are inevitable in life, either personal or professional. At the same time, remaining healthy is a responsible duty, and helping the distressed is highest virtue. Is there some way of effectively managing all the above requirements?
There is, in the form of culturally sanctioned attitudes and habits, as 'ideal human behavior', which is culturally universal. In an earlier article,  I have shown that this 'ideal human behavior' is same as or similar to: (1) desirable therapist qualities, and (2) health promoting factors of Ayurveda. Also, in the current mental health literature, some of its components are shown to correlate with well being. This ideal behavior or desirable therapist qualities can be acquired by practice. It also happens to be a natural byproduct of religious/spiritual practices.
Some components of spiritual practices like yoga-asanas, pranayama, and meditation are currently being used as means to prevent or cope with effects of stress. But, their effectiveness will naturally be in proportion to the extent that they are part of the whole. But, medical and mental health profession advocates holistic approach for its practice.
Then, why adapt only yoga-asanas and/or meditation, why not the whole total system? Why not become spiritual?
In this context, let me recount an earlier incident I remembered when, in the 1970s our seniors like Prof. Neki and late Prof. Venkoba Rao proposed Bhagavadgita as a psychotherapeutic paradigm. The incident happened in early 1940s in my home-town on the last day of a fortnight, two-hours-a-day discourse on Bhagavadgita by a well-known local Sanskrit scholar, Sri Chakravarti Iyengar. During the question-answer session, I had a question, "Did the two armies on the battle field wait for so many hours for Lord Krishna to complete His sermon to Arjuna?" Sri Iyengar's answer was simple and reveling, "No, Lord Krishna just touched Arjuna and brought about the required transformation in the latter's knowledge by His spiritual power. Bhagavadgita is only an explanation and commentary on the 'content' of the transformation that took place in Arjuna's 'living-knowledge'.
A question I like to pose for those who take this issue seriously is, "Why cannot we strive to become able to transform our patients in a similar fashion, even though to a tiniest extent?"
| Acknowledgments|| |
I am grateful to all concerned in nominating and inviting me for the Visakha Oration at the 41st Annual Conference of the South Zone IPS at Coimbatore on 4th October, 2008.
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