WE are into the third year of the COVID-19 pandemic and doctor wellbeing is an ongoing problem.
There are a multitude of supports and trainings offered from a variety of organisations (here, here, here, and here). It’s wonderful that there are so many resources to tap into. But burnout is a complex issue and there are no one-size-fits-all solutions, which is why I think I often have doctors coming to me wanting help because, as they say: “I understand what to do and why – I just can’t actually do it.”
So, with that in mind, I want to share some general principles drawn from a variety of approaches such as logotherapy, positive psychology, polyvagal theory and schema therapy that I use with my coaching clients (and myself) to help get past this impasse.
We are more empowered than we think
There are so many aspects of addressing doctor wellbeing that are out of our control. We can’t reform the health system overnight, and we can’t make COVID-19 go away. But it can be disempowering and counterproductive to continually consider ourselves as victims. Autonomy is one of our core psychological needs. And there is always something in our control.
As Viktor Frankl wrote in Man’s search for meaning:
… everything can be taken from a [person] but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way
I comfort myself often that if Frankl can find a sense of agency in a concentration camp, then there must be hope for us regardless of lockdowns, isolation, lack of personal protective equipment and rapid antigen tests, and confusing and changing rules. Although not easy, it is up to us whether we, as Frankl writes elsewhere in Man’s search for meaning:
make a victory of those experiences, turning life into an inner triumph [or] ignore the challenge and simply vegetate
The question is how.
These ideas (and many others like them) are inspiring, but they are often decontextualised, making them difficult to apply. So, in the spirit of empowerment, I want to discuss some of the general physiological and psychological barriers that make this so hard and, most importantly, some of the practical things that we can do to take back control so we are best placed to look after ourselves, our patients, and contribute to the wider discussion about the health system.
Physiological and psychological barriers to wellbeing
One of the roles of our autonomic nervous system is to constantly scan and assess our environment for threats and activate appropriate defences. This happens without conscious control, so even before we have consciously registered a threat, we will get sympathetic activation and our bodies start physiologically preparing to fight or flee.
This of course is incredibly helpful – if we need to run away from a bear. It’s less helpful when the threat, like COVID-19, is nebulous and invisible. It’s almost counterproductive when we have to treat our nearest and dearest as carrying a potential threat, because we lose access to one of our most helpful coping strategies – human connection. We end up on constant high alert, we perceive threats everywhere, and it gets progressively harder to regulate and manage the chronic sympathetic activation. In addition to the well known health consequences of chronic stress such as raised blood pressure and cholesterol, weight gain, irritable bowel and reduced immunity, stress also impacts our cognitive capacity. Polyvagal theory developed by Dr Stephen Porges (also here, here, here, and here) posits that when we are beyond a certain threshold of activation, we lose access to the higher cortical capacities not directly concerned with immediate survival. By implication then, as I see it, when we are chronically stressed, we are not in the best place to manage the stressors that face us in a constructive way.
According to the theories underpinning schema therapy and related approaches such as emotion focused therapy, chronic stress and sympathetic arousal can also trigger activation of unhealthy and maladaptive coping behaviours.
Throughout life we develop internal models of the world (schemas). These schemas are a complete bundle of (either adaptive or maladaptive) beliefs, thoughts, emotions and behaviour that result in a repertoire of subconscious rules and coping strategies designed to protect us from feelings of fear and shame. Maladaptive coping strategies are grouped in overcompensation, avoidance and surrender strategies.
For example, if we have an inner sense of not being good enough, we might overcompensate by trying to be perfect and developing unrelenting standards or by finding a sense of inner value with self-sacrifice and helping others at the expense of ourselves. Because these schemas are intended to be self-protective, it is very difficult to let go of them, even when they cause us harm. So, we end up trapped, continuing to overwork even when we know we shouldn’t. Because looking after ourselves threatens our core sense of safety.
Many schemas such as those relating to perfection or self-sacrifice are reinforced and valued in the medical world. We get praised and promoted for working hard, passing exams, and putting our patients first – even when it’s to our detriment. That’s what all good doctors should do, isn’t it? But this reinforcement can give schemas an even bigger hold over us and makes it even harder to break free of them. That’s why the idea “putting your own oxygen mask on first” may make logical sense – but at an emotional level it makes no sense whatsoever.
Taking back control
Even though these physiological and psychological responses are largely automatic and driven by subconscious processes, there are practical things we can do to regulate and soothe them as a starting point for bringing calm and choice back into our lives.
The following principles are a general (and necessarily incomplete) guide to this, although of course how they play out will be different for each person. I have developed these principles from my formal study and further reading, what I have found works with my clients, and of course, my own personal experience of trying to get stress under control.
- Seek connection and support
Connection with others is so important for our sense of safety and “okayness”. People who are able to empathically attune to us allow us to co-regulate, which is a capacity that develops from birth – picture a mother soothing a child – long before we learn how to self-regulate. So when we are finding it difficult to self-soothe, it’s really helpful and calming to tap into meaningful relationships.
We might find support from an encouraging a trusted friend, family member, colleague or mentor. Many people also want or need support from a professional trained to safely hold us. I believe it is a sign of strength to seek help and there should be no shame in reaching out to one of the many resources available to us, whether that is an employee assistance program, Doctor’s Health Advisory Service, Hand’n’Hand peer support or an individual coach, counsellor, psychologist or therapist. Of course, it’s also a good idea to see your GP.
- Notice and name
Many of us are so used to chronic stress that it feels normal. However, we can’t address the physiology and psychology of burnout until we get in better touch with what is going on in our body and mind and what emotions we are feeling.
This means noticing what is happening for us during and after challenging moments. Noticing where the tension is in our body, what our emotions feel like as we experience them. Noticing the different parts of ourselves that show up with fear and shame, how they may criticise us and how they often underpin our behaviours. This noticing process, termed interoception, helps us to begin to connect somatic experiences with our cognition.
Being able to put a language around what we are experiencing, and naming it accurately, is also an important component of soothing. As Dan Siegel says, when we can name what we are feeling, we can tame it. In other words, accurately naming what is happening helps calm down the whole system. Ideally, we would undertake this process in context of a supportive relationship. This is particularly important for those with a history of trauma. Self-help approaches to noticing and naming include mindfulness and self-reflection. Some might find Brene Brown’s book – The atlas of the heart – helpful in developing a broader emotional vocabulary.
- Calm and regulate
Polyvagal theory teaches we can actively contribute to calming our sympathetic nervous system by deliberately activating the ventral branch of the vagus nerve. This turns on the “vagal brakes” which moderate the sympathetic response and can help return our sense of safety and capacity to positively connect with others. As discussed above, connecting with others can help via co-regulation. Some other strategies that can promote immediate relief include:
- extended exhalations: around four long slow outbreaths (twice as long as the in breath);
- stretching and any form of tension release such as pushing your feet into the floor or pressing your arms or back into the chair;
- grounding strategies such as focusing attention on things you can see, hear and feel;
- self-hugs (and hugs from others too when possible).
There are any number of other individual strategies for nervous system regulation. Other favourite ways of mine for putting on the vagal brakes include sitting in a swinging egg chair and hot showers. Some might enjoy music and dance. Others might enjoy painting or craft. Longer term strategies such as diet, sleep and exercise all help keep our system regulated and reduce baseline activation.
Self-compassion helps soothe and regulate our nervous system. There is no one correct way to do self-compassion. Kristin Neff has developed a range of resources and strategies to help promote self-compassion. One of my favourite strategies for self-compassion is derived from schema therapy. In this approach we soothe unpleasant emotions and the accompanying unhelpful or critical self-talk that form part of a schema by recognising they are coming from a place of vulnerability, and although misguided, are genuinely trying to help us. We can then validate their perspective and have self-compassion towards those parts that hurt. “Yes”, we say to them – “thank you for sharing your fears and concerns for me and trying to keep me safe”.
Some may find a self-help approach helpful, but many will want and need the support of a psychologist, therapist or other trained professional to work through this and help heal the parts that needed a maladaptive schema to help them feel safe.
- Engage inner wisdom
Once we have regulated, calmed and soothed the parts of us that hurt, we can again more consistently access our higher cognitive functioning, which is critical for healthy coping and practising safe medicine too. We can turn towards our inner adult’s wisdom and remind ourselves that we have good coping skills, many strengths, resources and supports, have a track record of success in many domains – and feel capable of appropriate and proactive action.
It’s from this space we can truly understand the importance of putting on our own oxygen mask first. It’s from this space that we then engage in planning and enacting the self-care strategies we need.
So go well, stay safe, keep breathing and, whatever approach to burnout works for you, remember life is a team sport, we can’t do any of this alone.
Dr Jocelyn Lowinger has an Honours degree in medicine (1994), a Master of Science in Coaching Psychology and is currently studying emotion-focused therapy. A former GP, Dr Lowinger coaches doctors in proactive professional development, including helping them develop leadership skills, confidence and wellbeing. Visit www.coachgp.com.au
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The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.