On Solutions to Psychiatric Burnout

David Laing DawsonBy Dr David Laing Dawson

The anorexic girl is down to 84 pounds. It is time for her weigh-in. She stands on the scales, dressed as before, and, lo and behold, she now weighs 84.5 pounds. Excellent. You offer praise before you notice the suspicious bulges in the pockets of her sweats. And was that a whiff of ketones you smelled on her breath?

The call comes at 11 pm. Your patient is in emergency, suicidal. How can that be? You just saw her in the afternoon and not only did she say she was doing fine, but that you had been a big help.

He is agitated today, restless; his eyes scan suspiciously. You ask about his medication and he tells you he tossed his pills in the toilet. You ask why. He tells you he doesn’t need them anymore. In fact, he’s never felt better. And now he knows it is true. He does have a mission to spread the word of God. Or maybe he’s evil and should be killed. And then he’s standing, glaring at you, and you glance at the clock and see that your next patient has probably arrived, and you haven’t finished your notes from this morning, and the man in front of you was doing so well last month, and now — do you have time to talk him into going back on his meds? Is it safe to let him leave? What are the odds of the inpatient unit having a bed? What is that new process for admitting someone? And then the receptionist calls to tell you your next two patients are waiting.

He is depressed. There is no doubt he suffers from depression. Your pills, the combination he is on now, keep him functioning marginally. But he wants more Lorazepam to get through the day, and he’s already taking too many. He is overweight. You’ve talked about diet and exercise but the chances of him following a healthy diet and exercising daily are nil. He just wants to feel better. And you would love to be able to make him feel better but… And now he’s telling you he can’t make it through the day without more Lorazepam and you just finished reading how this drug shortens life expectancy….

He has chronic pain. It is real, and so are his traumas. But you know there is little you can do for him but listen to his complaints about all the doctors he’s seen, the insurance company, the Workers Comp, all their stupid decisions, and now because he has a tenant in his house paying rent they want to reduce his pension….So you listen, and you hope he doesn’t come back to see you, but you know he will because you listen, and he survives another month, and he is a hard man to like, but ….

Ah, the weight and burden of responsibility. People talk of Compassion burnout. Listening to all those difficult lives and tragic stories day after day, and trying not to take them home with you. But the faster route to burnout that I see among mental health workers is an assumption of responsibility for events over which they have no control, leading to a sense of failure, and then cynicism, anger and blame.

In other branches of medicine and nursing, responsibilities are usually clearer, not always, but usually.  Yours and your patient’s responsibilities.

Perhaps you advised against flying in the third trimester, after that little bleed. But your patient ignored this advice and flew to an American city and went into premature labour. You gave her the correct advice; she is responsible for her decision to fly.

You put a cast on and advise no weight bearing for two weeks. You are fully confident your advice will be followed.

You prescribe antibiotics for bronchitis. You know she will take them as directed on the bottle. She, your patient, may even know a little about the history of antibiotics, and how they work, and accept though the drug might have side effects, the benefits outweigh the risks, and she knows as you know that when it comes to bacterial infections, Amoxicillin will work better than megavitamins and positive thinking.

He has chest pain. You ask him to take his shirt off. He complies. He lets you take his blood pressure, listen to his heart. He will wait for the ambulance, let you take a blood sample. He will let you perform an ECG, send him down for an X-ray or CT scan. When you tell him what you think his diagnosis is, he won’t argue. You offer nitroglycerine and morphine. You admit him to hospital and discuss a bypass operation. He doesn’t tell you he disagrees with western medicine and would rather have an incantation, a healing ceremony, or take those little brown Chinese Medicine pills.

Burn out. The problem stems from the burden of responsibility without power or control. A mental health worker who repeatedly assumes (emotionally) responsibility for that which is either not within his or her control, or only marginally so, will become stressed, cranky, dispassionate, and begin to blame the patients.

In this work, dealing with, as examples, that first grouping of anecdotes, the mental health worker must constantly monitor his or her own assumptions of responsibility, know when to act, what he can change and what he can’t, when and how to assume responsibility, and when to sit back, offer compassion and understanding, but allow the universe to unfold, allow people to lead their own lives in their own way. It is a very difficult balance to maintain throughout every day of any mental health professional’s life.

That first girl. She’s cheating by putting rocks in her pockets, isn’t she? She’s making you look stupid. And you are doing your best. And it makes no sense. She is killing herself and you just can’t get through to her.

If that chest pain patient in the last medical anecdote dies of cardiac arrest you will know that you did everything you could to prevent that outcome. But the suicidal patient in the emergency room? What should you do? How much can you do? Is it even feasible to try to assume some responsibility for her actions, her behaviour? Did you miss something she didn’t tell you during that last visit? This is the third time she’s been taken to the Emergency in as many months. You know your colleagues in that department are now blaming you. They are also wondering how come you let your psychotic patients go off their medication?

To prevent burn-out, to prevent the development of cynical attitudes, mental health workers need a supervisory support structure that understands this perennial problem, this complex burden of responsibilities, and which provides mechanisms that help deal with it, help with it. Counseling, workshops, direct help, sharing, consultation, debriefings.

And all too often that administrative and supervisory structure does the opposite. It directly or tacitly blames the mental health worker for events he or she never did have the power to control.

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