In the furthest corner of the darkest café I could find, I holed up. Put my hands round my cup, pretending it was me and they would shield me from the outside, keep me warm for as long as it would take before I could get up the courage to leave here and head home. Head down, I turned away from the other occupants, and tried not to notice when a tear slid down my face. When I lifted the cup, my hands shook so much, I had to set it back down again.
I had not been out of the house for almost three months. I had cancelled some of the work commitments I had booked in, and staggered through others before collapsing into bed for a week afterwards. The shakes had arrived once the eight weeks of diarrhoea had stopped; the sleeplessness continued. And there was nothing, absolutely nothing that would effect even a glimmer of joy. Not my family, not my friends and not the trips I had coming up. The only thing I could think of each day was how soon I could get home and back under the duvet again.
I was lucky. My acute phase only lasted three months and I had good help from the state, my GP, counselling, physiotherapy and I poured out everything I could into a many paged leather journal. My therapist thought it had been a huge help in processing what was happening and allowing me to externalise the hurt. Another three or four months and I was almost me again.
So when I saw the headline in the New York Times, Is Burnout Real? I was fascinated. Written by a professor of psychiatry in the USA, the piece picked up on the recent upgrading by the World Health Organisation (WHO) of Burnout from a ‘state’ of exhaustion to a syndrome within its International Disease Classification. I had been expecting such articles, and was looking forward to reading this one.
As soon as I saw who the author was I was taken back to an event I had been running a few years ago with a group of psychiatrists in the UK. One, who looked to be approaching retirement after a long and I am sure successful career, asked me a question in the coffee break.
“I wonder if you can explain something for me?” he asked. “It’s the medical students. They seem to have, so many of them seem to have, well, issues, these days. I am sure it wasn’t like that ten, twenty years ago.”
With some retrospective embarrassment, I recall my reply, and hope he was not offended by my frankness, or that he felt I was being disrespectful.
“I wonder,” I suggested, “if your specialty has not been a victim of its own success.”
“Well, nowadays it would seem that not only is it acceptable for people to talk about having mental health issues, but the range of issues that you have accepted into your specialty has broadened too.”
He nodded and I ploughed on. “I am no expert in psychiatry,” I tried to excuse myself, “but it would seem that the spectrum of mental health illnesses has widened. And if that is the case, then I guess there will be more people with those issues, like the students.”
Was I, I now wonder, saying the same thing as Dr Friedman in his article: “Let’s not medicalise everyday stress and discomfort as burnout?” Is that what my psychiatry colleague was asking me? Was that what he thought I had said? I shudder as I write this. Because I don’t think it is so clear cut.
Burnout, most would agree, seems to be an identifiable phenomenon characterised by physically, cognitive and emotional impairment. It can result from prolonged stress, but is not the same as stress. Stress, a new word to those who returned from the Wars, is a vague term which can apply to a range of responses from a trip to the dentist, some maths homework or something far longer. We have often talked about ‘good stress’ which stimulates us, challenges us and ensures we get things done, and ‘bad stress’ which might not lead to a positive outcome if we are sent over the edge of the Yerkes-Dodson tipping point. I remember my grandfather telling us we didn’t know the meaning of the word stress, having never gone to war. We can also distinguish between external and internal stress, and stressors. But burnout seems to be more specific, and as such needs specific description.
Burnout is defined by emotional exhaustion, perhaps an inability to empathise or to care. There has been much written already about burnout in healthcare and also in other areas of public service such as teaching and police work. The work rate of those with burnout seems to be affected adversely with people reporting a sense of inefficiency which causes more emotional worry. And there is often a disconnect for them so that those who have spent all their lives so far in caring or public service roles suddenly find themselves incapable of believing in those roles any more. Bizarrely I found my politics moved from left of centre to right of centre, which had never happened before and thankfully has been rectified, but I just was not able to care about anything or anyone.
One of the debates about burnout focuses on whether it is the individual or the context which is at fault. Many of the early attempts at minimising or even curing burnout saw individuals being encouraged to practise mindfulness, yoga or relaxation. Other people argued that we need to treat the cause and not the symptoms and that the workplace is usually guilty of creating the pressures that lead to burnout. Certainly we know from Michael West’s work that the link between staff wellbeing and patient safety and good outcomes is clear. If we are well cared for we are usually more able to care for others.
In the comments under the Friedman piece one person tells of a career of 26 years in schoolteaching that ended prematurely when they left as the profession had changed beyond recognition. Others come from doctors who have also burned out due to the managerial pressures of their clinical roles. Wendy Dean and Simon Talbot use the term “moral injury” to describe the type of stress that occurs when we are not able to live up to our ideas due to systemic conflicts. The teacher who left claimed her workplace was once “collaborative and caring” and is now a “competitive, fast paced treadmill.”
Another commentor claims that mental ill health is ambient – all around us; we are surrounded by it. If indeed our brain uses ‘mirror neurons’ which put our brains into the same emotional state as those around us, then maybe we are adversely affected by the dissonances within the public sector? We go into healthcare, education, working with the public, often from a vocational sense of wanting to help. At first that is mirrored back to us, from patients, families, students and parents, and we inhabit a community of collaboration and care, where we are all working to the same end.
To say there was no stress during the war is disingenuous. Of course there was. There was the stress of wondering if your house would be obliterated each night, if your husband or son or father would come back from the front. And if they did, would they ever be the same again. We tried denying the existence of one form of mental illness after the First World War – which did not help those with Post Traumatic Stress Disorder – or shellshock as it was then called. Shellshock was humankind’s way of saying that what had happened was inhuman, and maybe burnout is the human way of red-flagging something that our societies have not yet realised is also inhuman – the erosion of human effort, the killing of creativity, the alleviation of professional autonomy and the destruction of humanity and its ability to care for one another.
Of course a bad day at the office is not burnout; but let’s look further at what is causing this so called epidemic. Reducing the agency of a highly trained professional into a series of protocol driven conveyor belt practices, limits their efficacy and effectively lobotomises their ability to care. By pushing people further to see more patients, teach more students, but to do so less well, with no space for individualisation, adversely affects their lifelong devotion to others. It makes us people we despise. We don’t recognise the professionals we have become. Society, in trying to make more for less is reducing everything to nothing. Just as the men who returned from war returned to a changed world, we now inhabit a world that was changed irrevocably by the crash of 2008. With no security to speak of, no guarantees of employment, no future to look forward to, is it any wonder that those of us who remember the past, cling on to it and its ways of working? Is it any wonder the younger generation are burned out before they start? With nothing to believe in, there is precious little to live for.