Shirah Vollmer MD

The Musings of Dr. Vollmer

Burn Out

Posted by Dr. Vollmer on June 13, 2016

What happens when the provider does not care any more? Is this shameful? Unspeakable? Is it a problem of the health care delivery system or an inherent issue with the helping profession? Does it stem from a deep question of efficacy or simply fatigue and poor self-care? How do providers discuss this without feeling judged? After all, “I want to help people” becomes a mantra for admission into a caring profession. To think, not even to say, that there is a strong tug to not want to help, to do something else, or think about something else, is akin to a massive betrayal, a betrayal to oneself, perhaps, but a feeling of betrayal nevertheless. And so, at times, begins provider substance abuse. Saying “I have a problem with addiction” is more favorable than saying “I don’t want to keep doing what I am doing because I simply do not care.” Lucy, thirty-two, comes to mind. She worked hard in her private élite high school to go to her private élite college and then to her private élite medical school and then to her high-prestige psychiatry residency. She graduates with massive debt, and scores a high-paying job, prescribing medication to patients in rapid fire. At first, she is happy with her new-found income, and hope of paying down her loans, but as time goes on, as days begin to feel longer, and weeks unending, and Sunday nights, simply dreadful, she finds herself unhappy and unable to be honest about it, with herself. She begins to take pain pills, as her chronic back pain, seems worse, perhaps because she sits all day, and perhaps because her mood is so low, that every ache in her body is accentuated. At first she functions at work, taking opiates, but as time goes on, she needs more and more pills to function, and eventually she starts missing work, culminating in her admitting that she has an opiate addiction, but not admitting that she finds no, or little satisfaction in her job. She welcomes the opportunity to go to a rehabilitation facility, and she welcomes the break from her friends, her job, and her responsibilities. She is a model rehab patient. She is thoughtful and participatory. She feels the rehab has saved her life and she is grateful for the experiences. She is discharged from the rehab after sixty days, and she returns to work, and within days, her opiate use returns. Once again, my point is simple. Lucy does not have a problem with opiates, but rather, she has a problem dealing with authenticity, and as such, opiates provide a clean escape from her fraudulent self. Facing the satisfactions and disappointments in her life, in her choices, in her daily routines, is nearly impossible for Lucy. It is much easier for Lucy to look externally and say the problem is the opiate, and not with the way she has set up her life. Addiction treatment programs, in collusion with Lucy, propel this forward. Rather than promoting long-term, continuous care, there is an emphasis on relatively short-term care, which often becomes a revolving door, with changing treatment teams. As such, there is burn-out in the staff, making it even harder for health-care professional patients, to face their own burn-out. To combat the issue, the values need to change. Placing a value on truth, self-truth, puts all feelings and ideas as fair game, no matter how bad they might sound. This is what Freud taught us. Speak first, no matter how difficult that might be, and then work with your thoughts and feelings after that. This is his notion of “free association”. With this freedom comes a personal truth which leads, as he would say, to the ability to love and work. With those abilities, no escape is necessary. Lucy could be set free from her trapped existence.

2 Responses to “Burn Out”

  1. Shelly said

    Shirah, I was a little confused if you were writing about burnout of the treating therapists (staff), therapist-patient, were blogging about the value of free-association as the cure to burn-out because it brings forth truth, or what? Yes, opiates are a mean to dull the pain of being dissatisfied with her life–a life viewed from the outside–should be perfect. Like everyone else who is addicted to something, Lucy is unhappy. Rehab obviously weans her from the opiates, but does not help her reorganize her life so that soon she is back to self-medicating with opiates. You then mention burn-out of addiction treatment teams. And finally you speak about “free association.” Please can you clarify how all three are connected in this blog?

    • Yes, Shelly, I was purposefully vague about how these issues intersect. The issues, as you state, of opiates as an escape hatch from being inauthentic, to burn-out in helping professions, and finally, the shame of not living up to one’s own expectations. These issues connect in a way which makes mental health confusing for the patient as well as the provider. Free association is one tool which promotes personal honesty, and in so doing, is one way to help with mental suffering. The other important tool is a long-term relationship with a mental health professional. This relationship is often critical for the long journey to recovery for mental anguish. Honesty on both sides of the couch is critical to the success of this relationship. The therapist has to provide steadiness and consistency for the patient, while at the same time, the therapist needs to be vigilant about self-care. My final point, which you understand clearly, is that one of the current issues with mental health care is that the focus is on the symptom, in this case opiate addiction, and not the underlying issues which preceded the self-abuse. Thanks, as always, for helping me articulate my thinking. Please let me know if I can further clarify these issues.

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