Burnout, mental resilience and thriving

Burnout and Resilience Talk CMC22

Dr Greg Jemmett

20 Aug 2022

Burnout is NOT a medical diagnosis. I reread the words, and inside felt a deep sinking feeling. Surely this couldn’t be the whole truth? I’d been seeing patients with burn-out for the last 7 years as a GP, and had been diagnosing them based on the presentation of extreme exhaustion due to chronic and overwhelming work stress. Most often my prescription for these patients included time off work, advice on improved sleep hygiene, regular exercise, a better diet, relaxation exercises and the encouragement to have firmer boundaries at work. If depression, anxiety or insomnia presented itself, then I would refer for psychotherapy or counselling, and medicate as appropriate.

My eyes refocused on the page as I continued reading.?I was on the World Health Organisation’s website, which I’d clicked on after a Google search took me there on the topic of burnout. The page told me burnout was an ‘occupational phenomenon’, and that it was the result of chronic workplace stress which had not been successfully managed. I was aware that Burn-Out had a diagnostic code according to the ICD 10 and 11 (International Classification of Diseases), but that it was not included in the DSM 5, the Bible for mental health diagnoses and conditions.

How was I then to legitimately face my patients and try and help them if they didn’t have a medical condition when they sought my help? Then I remembered something which had been tucked away into my memory for over 20 years. It was a definition I had learned as an undergraduate medical student, and it came from the World Health Organisation’s Constitution: ‘health is a state of physical, mental and social well-being and not merely the absence of disease or infirmity’. Importantly then, mental health is more than just the absence of mental disorders or disabilities. I began to see it more clearly. My vocation as a doctor was not only to diagnose and treat diseases, but also to promote health, and naturally mental health is a vital part of general health.

And of course, the reason why each one of us is here today, is because of mental health, thanks to the organisers of this event.

Within this context then, it is important to ask what burnout is and then ask how burnout affects mental health? The term burnout was first officially used in the early 1970s by psychotherapist Dr Freudenberger to encompass the phenomenon of exposure to chronic job stress. Dr Christine Maslach, a social psychologist, went on to further define three core components which she thought needed to be evident in burnout:

1.??????Feelings of mental and physical exhaustion

2.??????Increased mental distance from one’s job, with feelings and thoughts of negativity and cynicism toward one’s work

3.??????Reduced personal efficacy at one’s work and a negative view of oneself or one’s competence

Research shows that burnout is known to more likely affect those who work in human services: healthcare, education, social work, counselling and psychotherapy, legal services and law enforcement. Even social media content creators and influencers are not immune from its effects. The research has grown exponentially over the last decade and shows that anyone in any job can experience burnout.

While there is more interest in studying burn-out in our current setting, it could be argued that burn-out is an ancient human phenomenon with examples in texts like the Psalms in the Bible. Listen to these quotes and see if you can make the connection: ‘I am exhausted and completely crushed. My groans come from an anguished heart’ and also: ‘the floodwaters are up to my neck. Deeper and deeper I sink into the mire, I can’t find a foothold to stand on’. One isn’t hard pressed to see an exhausted human services worker at the end of a week of long shifts uttering these words, particularly during the time of COVID.

Burnout may often be confused with depression. It can also overlap with depression, or in fact may lead to depression. A previous episode of depression may make one more vulnerable to the development of burnout. Depression is a diagnosable medical condition. It usually comprises of a low mood, decreased energy levels, loss of interest in activities one usually enjoys and may involve suicidal thoughts. These symptoms would need to be present for at least two weeks for depression to be diagnosed. Depression is best treated either with psychotherapy or counselling if mild to moderate, or antidepressant medications and psychotherapy or counselling if more moderate to severe. Other medical conditions which may mimic burnout or depression are: chronic fatigue syndrome, long COVID, insomnia, an under active thyroid, anaemia or iron deficiency or various vitamin deficiencies.

The next important question to address is why does burnout present? Dr Maslach’s research shows there are six factors in the workplace which drive the phenomenon:

1.??????Workload

2.??????Control

3.??????Reward

4.??????Community

5.??????Fairness

6.??????Values

In terms of workload: it may be that there is a mismatch between a person and their job. There may be high demands with a very high workload, but few resources or not enough time to meet the demands.

Control : relates to how much autonomy, discretion and choice is available in the work setting.

Positive feedback is important in the realm of reward. This allows social recognition, and can also bolster internal reward mechanisms. Some people might think that a good day is when nothing goes wrong, but this in fact means that there is a lack of positive aspects to the job at hand.

Community: speaks of the people one interfaces with during the work day. These could be work colleagues, employees, employers, clients, patients. Is the community a supportive environment, or is it toxic?

Fairness: is self evident. Are rules and policies being applied equitably across the board, or is there disrespect, the presence of glass ceilings and discrimination which can lead to cynicism.

Lastly, is the issue of values: is there meaning in the work being done? Is there pride in the work? Is the work making a an appreciable difference in the world, or is there an environment where there is a conflict of values and ethics?

Many people might feel that they are simply overworked, and that the problem is merely a workload issue. However, if they looked more closely at the realms mentioned, they might be well realise it could be a number of other factors causing their chronic occupational stress:

When considering occupational stressors, Dr Maslach described 5 different scenarios:

1.??????Burnout, where all three factors of exhaustion, cynicism and reduced efficacy are present

2.??????Disengaged, where there was negativity toward one’s work only

3.??????Overextended, where the workload was too much, and the person was exhausted

4.??????Ineffectiveness were there was reduced personal efficacy and negative views of oneself and one’s competence

5.??????Engagement: where there optimum functioning.

In order for an individual to reach the engagement stage they would need to ensure that they had addressed the issues of workload, control, reward, community, fairness and values. Yes, there may well need to be reflection on internal boundaries and self- care, but burnout is important as an occupational phenomenon and therefore the workplace environment needs to be addressed. There may well be time for rest to recharge, but if after a period of leave one comes back to the same toxic work environment it won’t be long before burnout presents itself once more. Conversations need to be had with loved ones, with colleagues and with employers and managers. Additionally, one should seek help from professionals such as your primary care doctor or mental health practitioner. Burned out workers are more likely to take sick leave and be less efficient at their work, which has a negative economic impact. Everyone knows what absenteeism is, but presenteeism is an occupational phenomenon too. Presenteeism happens when someone shows up to work despite being impaired by burnout or illness. This was more likely the case during the time of COVID due to increased work pressures and concerns about job security. In addition, working remotely from home has added additional pressures of not easily being able to place firm boundaries between the home and work. It’s estimated that presenteeism costs more than seven times the loss of productivity than does absenteeism when one if impaired and not at work.

While burnout cannot be resolved simply by self- care, due to the occupational factors mentioned, I do believe that self- care plays a vital role in good mental health and recovery from burnout, and not only this but the development of mental resilience. So here is the second part of my talk.

Here’s a quote to illustrate: 'Take a rest; a field that has rested gives a bountiful crop.' Ovid

It's interesting to note that top athletes and sports people have a non-negotiable approach to rest and recovery in their training schedules. These time periods allow their bodies to strengthen and repair themselves between workouts or events. They also allows the athlete to recover psychologically and physiologically in order to be able to reach peak performance when required. These periods of downtime are not ad hoc, but are deliberately designed to integrate into the whole approach to training. They can be further divided into short-term and long-term recovery, which each have their own particular design aims to bring out the best in the athlete.

Enter as a counterpoint the experience of Arianna Huffington, a successful individual by anyone's standard. She is a syndicated columnist, top businesswoman, and co-founded The Huffington Post. However, in her book 'Thrive' she recounts a watershed period in her life in 2007. Prior to this she had internalised the maxim that burnout and exhaustion were the necessary trade-offs for success. In 2007, however, she passed out from pure sleep deprivation and exhaustion, and injured her head on her desk, sustaining a skull fracture. This spurred her into action. She set up and became CEO of Thrive Global and authored a number of books to 'improve people's mental resilience, health and productivity in the new normal and beyond'. She styles herself as a sleep evangelist, and since prioritising sleep has found that this has allowed her to change her habits, and wake up to the day's possibilities rather than grinding through the day's agenda on a half empty awareness. This has also allowed her to better recognise danger signs of old unhelpful burnout behaviour returning, and also to be more resilient in the face of challenges.

Sleep hygiene has been well known since the 1970s. Since then a set of principles have been applied to an individual's sleeping habits to successfully manage mild to moderate cases of insomnia.

Arianna has her own set of guidelines which have helped prioritise her own sleep:

1. Digital detox 30 minutes before bedtime?(a blue-light emitting device affects your body's circadian rhythm)
2. Taking a hot bath before bed?(this acts as a transitional action, which relaxes the body and mind prior to slumber)
3. Change into comfortable sleepwear?(this signals to our brains the additional transition to bedtime, and that our body is in the process of gearing down from the day's events)
4. Keep your bedroom dark, quiet and cool?(this has been shown to aid a better and less interrupted night's rest)
5. Avoid caffeine after 14:00?(this may be difficult for many of us, as we thrive on caffeine in an exhausted state. However excess caffeine disturbs our sleep quality, making us require more the following day and potentially setting up a self- defeating cycle of over caffeination and sleeplessness).
6. Remember the bed is only for sleep and sex?(other associations with the bedroom such as TV or work can add subconscious signals to our brains which might introduce work anxiety, or modulate our habits to anticipate digital entertainment).

While there certainly are other habits to inculcate regarding sleep hygiene (such as moderate daily exercise or deliberate stress management such as journaling and making lists), in an increasingly burnout- oriented culture, let's start learning to thrive a little more each day by ensuring we get sufficient rest at night.

This brings me to my next point about learning to thrive. There is a reason social isolation is used as a form of torture for prisoners of war, or punishment in various prison systems around the world. Even if an individual were to start that isolation period with a good degree of physical and mental health, the process would ultimately be the undoing of their very physical and mental integrity. We are quite simply built for social relationships, and social science data is clear: adults who are more socially connected fare better on health and longevity indicators than their more isolated contemporaries.

Ebenezer Scrooge, in Charles Dickens' morality tale 'A Christmas Carol', experiences a series of ghostly encounters which give him insight and perspective into the lonely, selfish and unfulfilled life he lives as a miser. With spiritual prompting, he begins to see that his life is not just about himself, but that his inaction in assisting others has severely negative consequences for those whose plight he chooses to ignore, but also ultimately and ironically that his own life is much poorer for it. Scrooge's isolation is a self- imposed one, where he has exchanged love of his fellow people for single-minded pursuit of the love of money. In the end (spoiler alert) he has a complete change of heart, and seeks to encourage and bless those around him to help them thrive financially and relationally. This is turn fills his own heart with joy and a sense of belonging.

The common theme in the above examples, is that they both speak to forms of imprisonment, even though the second was wilfully chosen by the character. Naturally, this hampers human relational thriving. And as mentioned above, social ties are key determinants of mental health. But how exactly is this the case?

According to a study by Umberson and Montez , in the Journal of Social Health and Behaviour (2010), there are three key areas where our health is affected by relationships:

1.??????behavioural

1. psychosocial
2. physiological

Health behaviours are wide- ranging and can account for an astounding 40% of premature mortality in the USA. Some behaviours promote health (ie healthy eating, exercise, medication adherence), and others undermine health (ie smoking, weight gain, heavy alcohol consumption). Social ties have a way of influencing and controlling health behaviours by instilling a sense of responsibility and concern for others, and further creating norms which influence health positively.

Psychosocially speaking; social support, personal control and mental health are key factors. Social support can create emotionally sustaining relationships, which can further ameliorate the effects of stress, and create a sense of meaning and purpose in life, and thereby also increase resilience to burnout. Personal control, like Scrooge's epiphany, highlights that a person comes to believe they have agency in their lives to change health outcomes. Mental health can be complex, but one of the simplest effects of psychosocial support is to enhance psychological wellbeing. This in turn can have the added benefit of not wanting to engage in health compromising behaviour and may in fact rather promote health seeking behaviour.

Focusing then on the micro level of physiology, there are very well documented effects of healthy social relationships on improved hormonal, cardiovascular and immune function. In fact, emotionally supportive childhoods result in the healthy development of metabolic and nervous system regulatory function. And extrapolated into adulthood, continued supportive environments reduces physiological reactivity to real and anticipated stresses. Job burnout included.

The truly encouraging reminder in all of this is that relationships involve an exchange, and an ongoing bilateral flow of influence. Having said that, perhaps in a world of multiple social intersections and job demands, this could be your own spiritual prompt:

'Whoever brings blessing will be enriched, and one who waters will himself be watered' Proverbs 11:25

Wishing you good social relationships, optimal mental health and a burnout free future.

Thank you.