Anne O’Connell, MD, PhD

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.
  

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.
  

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.