Handling ethical dilemmas is the most common cause of poor wellness in veterinary medicine, in the opinion of psychotherapist and compassion fatigue specialist Elizabeth Strand, PhD, and moral stress is the biggest contributor to compassion fatigue in veterinary medicine.
Dr. Strand, an associate clinical professor and founding director of the Veterinary Social Work program at the University of Tennessee, addressed the human perspective of compassion fatigue Nov. 4, 2014, during the AVMA Humane Endings Symposium near Chicago.
The UT Veterinary Social Work program was founded in 2002 as a partnership between the UT College of Veterinary Medicine and College of Social Work. Individuals working in the area of veterinary social work focus on four areas: the link between violence against humans and violence against animals, grief and pet loss, animal-assisted interactions, and compassion fatigue and conflict management.
“We’re not here to address the animal issues; we look to veterinarians to do that, but every animal usually has attached to it some type of a human being, and so that is where our purview is,” Dr. Strand said.
Sources of stress that create poor wellness in veterinarians include giving bad news, managing adverse events, interacting with difficult clients, working in teams, and balancing work and home life. But handling ethical dilemmas is the worst stressor, and Dr. Strand said research indicates that veterinarians face ethical dilemmas three to five times per week.
She described a recent study (Vet Rec 2011;168:263) that looked into veterinarians refusing to perform euthanasia when they didn’t think it was the right thing to do, or performing euthanasia when they wished they could refuse to. Though the study showed that both happen infrequently, she said the take-home message is that animal-based reasons appear to be central to those decisions, yet pressure from the owner had an impact on the veterinarian’s decision. Social pressure within an organization was found to be related.
In animal sheltering environments, some of the things that contribute to poor wellness are the frequency and intensity of euthanasia, dealing with the public, dealing with animal cruelty, conflict within the workplace, and the constant stream of animals.
Dr. Strand noted that some stress is necessary for achieving one’s best performance, but poorly managed stress can result in burnout, substance abuse, depression, anxiety, relationship distress, a negative work–home life environment, and even suicide. A well-designed study by Dr. David J. Bartram found veterinarians were 5.5 times as likely to have suicidal ideation or thoughts than were members of the general population, she said. And in a 2012 study (J Vet Med Educ 2012;39:79-82), 66 percent of practicing veterinarians who responded stated that they had clinical levels of depression, and 24 percent of them reported seriously considering suicide. This compares with the national depression rate of 6 to 8 percent. Dr. Strand noted that 66 percent of veterinarians contacted for the study responded, so the study was limited by self-selection.
A study published online Aug. 16, 2013, in the Veterinary Record, found that 13 percent of veterinary students had seriously considered suicide, and 19 percent had received a diagnosis of mental illness. The study indicated that 54 percent of students said they were experiencing a mental health issue when they came into school, and 25 percent of them had seriously considered suicide.
It used to be that, if I’m willing to take care of myself, my mental well-being, I’m going to take a vacation. But that goes against this incredibly honorable work ethic that veterinarians have that I’ve never observed (elsewhere).
Dr. Elizabeth Strand, PhD, founding director and associate clinical professor, Veterinary Social Work, University of Tennessee
Dr. Strand said a study on suicidal behavior and psychosocial problems in veterinary surgeons (Soc Psychiatry Psychiatr Epidemiol 2010;47:223-240) was the first to link compassion fatigue with suicide as well as factors such as workplace relationships and number of hours worked. Co-occurring difficult life events contributed to this issue.
“Moreover, the possible risk factors that may be associated with why there’s this rate of suicide in veterinary medicine … should be addressed in the veterinary profession and in veterinary medical institutions,” Dr. Strand said.
She highlighted another study (Suicide Life Threat Behav 2013;43:125-138) of veterinary students that found that habituated exposure to euthanasia was associated with fearlessness about death. She said that though she is a mental health professional, even she was reluctant to discuss mental health issues in veterinary medicine because of the stigma associated with them. All that changed when one of her students, the late Dr. Norman Paul Nolen, committed suicide a year after leaving the UT veterinary college.
“For me to be here after 12 years working with this profession and speak so plainly about these issues is really bold for me. I would never have done this, years ago,” she said. “And the reason I do it now is because of Paul’s note. It makes me unabashed about speaking plainly about these issues. He wrote in his suicide note ‘I would love for there to be more encouragement for professional students about mental health and support for those with mental health problems.’”
“Of course, sadly, we also lost Dr. Sophia Yin recently to suicide,” she said, and the late Dr. Edith Klein, who took her own life as well as her six pets’. (Watch for an article and obituary on Dr. Yin in Jan. 15 JAVMA News.)
Dr. Strand said the good news is that the AVMA (and Zoetis) sponsored the first health and wellness summit in 2013 at The Ohio State University, and the Association of American Veterinary Medical Colleges (and Zoetis) sponsored the second one Oct. 8-9 (see JAVMA, Dec. 15, 2014).
Redefining veterinarians’ work ethic
Veterinarians face the moral stress of euthanasia every day, and Dr. Strand thinks they must take intentional steps to promote their own and their staff’s wellness. This is nonnegotiable, she said. As professionals, veterinarians have the responsibility to provide a work environment where their staff members can deal with the stressors of their work.
“It used to be that, if I’m willing to take care of myself, my mental well-being, I’m going to take a vacation. But that goes against this incredibly honorable work ethic that veterinarians have that I’ve never observed (elsewhere),” she said.
“However, at this point, I think the research is there to say that maybe we’re having to redefine what is the ethical responsibility, that it includes not just working really hard but also keeping oneself well so that you can continue in the work and help with the other people in the profession or in your clinics,” she said.
Her definition of compassion fatigue is the result of caring very much and working very hard, but at the same time, not recognizing and caring for your own needs.
Signs of compassion fatigue are the presence of a traumatic event such as repeated exposure to euthanasia, loss of desire to do work, and intrusive experiences while not working—reliving something negative that happened. This is not a sign of something gone wrong but is the way human beings function. Examples of “self-talk” that indicate compassion fatigue are: if I don’t do it, no one’s going to do it; no one cares as much as I do; no one else can do it the right way; I’m the only one who can take care of this; if I don’t resolve every problem, I’ve failed; I don’t want to burden others by taking time to care for myself; and I can’t believe he’s taking time off, clearly he doesn’t care as much as I do. The compassion fatigue trajectory encompasses the zealot phase, withdrawal phase, irritability phase, and zombie phase, but these phases are cyclical rather than linear.
Burnout is related more to the loss of desire to do the work anymore and not necessarily to the trauma.
“The one that has been the least researched and that is the biggest contributor to compassion fatigue in veterinary medicine is moral stress. Moral stress is when you’re aware of what ethical principles are at stake, but external factors prevent you from doing (something).”
She said the classic example is knowing that an animal should be euthanized, but the family is not willing or ready. Moral stress is unique and insidious in that it cannot be alleviated by normal means of stress management. It arises among people whose life work is aimed at promoting the well-being of animals. Whereas lying on a beach for a week will alleviate burnout, someone experiencing moral stress or compassion fatigue who lies on the beach will have all the unwelcome images come crowding in.
“You’re my species”
Morality is almost always conflictual because one’s own interests can be opposed to others’ interests.
“Moral sensitivity is not just about your thinking, it’s also about your awareness of yourself and the other person, thinking, feeling your emotions, and also your actions. That’s why you’re my species; I’m not just interested in what you think, I’m interested in what you’re feeling and what you’re doing with those feelings because that’s where the rubber meets the road in managing compassion fatigue,” Dr. Strand said.
People who work for organizations that have “moral climates” where they can discuss their moral dilemmas and benefit from other social support seem to have better outcomes, Dr. Strand said. In sheltering environments, positive outcomes are also associated with being able to vent feelings, decrease one’s emotional attachment to animals, and know that euthanasia is best under the circumstances.
Group time to discuss and debrief is important because it allows integration of implicit memories—such as some traumatic images that keep coming into one’s mind. When a group of people who have such memories talk about them together openly, the memory moves from the implicit, lower parts of the brain to the cortical part of the brain to become explicit. Dr. Strand said once that happens, a person can make sense of it. However, this requires a facilitator with expertise in that area.
She said one thing that can be done on one’s own is expressive writing, which has been shown in a sheltering environment to provide very beneficial results. Every day, spending 15 to 20 minutes writing in a journal what stressed you out that day similarly moves things from implicit to explicit memory.
Dr. Strand offered some nutritional ideas supported by research that may be protective regarding compassion fatigue, among them, eating foods with omega-3 fatty acids and yogurt. Students who took omega-3 fatty acids had reduced anxiety symptoms before examinations, for example.
“Sleep, I know you’re not getting enough, you’re supposed to have seven to nine hours. It’s OK if you don’t get it this week, but if you don’t catch up, over time, lack of sleep is associated with significant health problems and permanent brain damage,” she said.
Finally, she encouraged veterinarians to try meditation, a method whose benefits have been shown in research studies over the past 20 years. Dr. Strand, who has practiced meditation all her life, suggested that those who want to learn to meditate with no religion involved should try mindfulness-based stress reduction by going here or typing “MBSR” into a search engine to locate training on how “to be in the present moment.”
Related JAVMA content:
Finding calm amid the chaos (Nov. 15, 2013)