In this second article of our series exploring the health of health professionals, consultant psychiatrist, Dr Richard Duggins, introduces simple techniques for managing stress, and also recommend where doctors and other health professionals suffering psychological distress or addictions can seek advice, support and treatment when it is needed.
What is stress?
Stress is a feeling of threat; it is the flight or fight reflex. It lets us know when we feel external demands exceed our ability to deal with them. Unfortunately, our body reacts in the same way whether the external demand is a big fierce dog we can run away from, or day-in day-out overwhelming work we cannot take flight from (though we might want to). This explanation of stress lets us know the solutions are simple. We have two options; reduce the external demands on us, or increase our ability to deal with them.
Why managing stress keeps health professionals healthy
The stress-vulnerability model of psychological illness makes it clear that by managing the stress in our lives we can reduce our likelihood of developing psychological distress and illness.1 This model is represented in the diagram below, and illustrates that psychological ill-health is a result of an interaction between personal vulnerability and precipitating stress.
Those people on the left side of the diagram with a low personal vulnerability to mental illness need considerably more stress to make them unwell. What this model illustrates so beautifully is that none of us are safe from mental ill-health; a large enough amount of unmanaged stress still risks making a health professional unwell even if they have a low personal vulnerability to mental illness.
Simple techniques for managing stress
The good news is there are many “easy-wins” health professionals can make to reduce their odds of suffering overwhelming stress, and therefore reduce their likelihood of suffering mental ill-health. These techniques can be separated into ones that reduce external demands, and ones that increase our capacity to deal with these demands.
Managing stress by reducing external demands
[Health professionals] find it very difficult to accept they might have a limit on the amount of work they consume. Health professionals seem to take on more and more work as if there is no healthy upper limit.
We all find it very easy to accept that most things in life have a limit, for example if we regularly eat beyond about 2000 calories a day, we are likely to put on weight and damage our health. Unfortunately, my experience of working full-time treating health professionals has led me to conclude this group especially find it very difficult to accept they might have a limit on the amount of work they consume. Health professionals seem to take on more and more work as if there is no healthy upper limit. Of course, the actual healthy limit varies enormously between different people, and tends to be very high in doctors and health professionals, but nevertheless there is a limit, and working beyond it leads to stress and burnout. Other aspects of life also impact on how much work can be healthily managed, so if a health professional is having a challenging time at home, or has recently suffered bereavement, their work limit will be lower.
Changing the way work is managed, even in situations when the amount of work cannot be easily reduced, can reduce the perceived demand of the work.
Changing the way work is managed, even in situations when the amount of work cannot be easily reduced, can reduce the perceived demand of the work. There are various techniques health professionals can use to work more effectively and as a result take the weight of their shoulders. Steven Covey’s “Seven Habits of Highly Effective People” is invaluable in its advice on how to prioritise work, be assertive, and set achievable goals.2 David Allen’s “Getting Things Done” is also a very helpful guide to managing demands and scheduling their completion.3
Managing stress by increasing our ability to deal with demands
There are a variety of simple evidence based techniques, which increase our ability to deal with demands. Regular physical exercise has been shown to buffer the effects of negative life events, good sleep hygiene boosts our resilience, effective social support and a confidante to talk with reduces vulnerability to mental ill-health, and relaxation and meditation techniques (such as mindfulness) are protective against stress.
We can also increase our ability to deal with demands by making changes to how we think about these demands. Everyone views the world in certain ways as a result of their upbringing and temperament, and for doctors and other health professionals this characteristically tends to be in rather perfectionist and high standard ways. Psychotherapy, especially CBT techniques, can help health professionals “catch” their thoughts, “check” them and if appropriate “change” them. For example, if a health professional with very high standards misses a non-life threatening diagnosis, this may trigger a chain of negative thoughts such as, “I am useless doctor, I always screw up, I will miss something serious next time, I must work harder”. This way of thinking leads to anxiety and stress, and makes work seem more overwhelming and demanding. CBT techniques would help this health professional ask if there was an alternative (and more realistic) way of thinking about the missed diagnosis, which may be, “I regret I missed it, but the symptoms were odd and the surgery was pressured. I am much less likely to miss something similar again because I have learnt from this.” This different way of thinking results in the health professional feeling reflective, more positive about the future, and as a result this makes work feel more manageable. Such changes in thinking can be relatively easily learnt, and a variety of self-help books and online packages can help with this.4,5,6,7,8 Engaging with a mentor or psychotherapist can also make a big difference in managing the demands of work, especially for health professionals who are excessively self-critical.
How to seek effective help
Psychological difficulties or addiction problems are common in doctors and health professionals, although these professionals often struggle to know where to turn for help. As I outlined in the first article in this series, health professionals find it easy to help others, but can feel failures if they need help themselves; feelings of shame, stigma and fears around confidentiality act as barriers to effective care. However, when appropriate treatment is accessed, the evidence is overwhelming that health professionals make rapid, full and sustained recoveries.
The first port of call for any unwell health professional should be their GP. Many doctors by-pass the system by “corridor conversations” with specialists, but these are risky as GPs offer the best comprehensive initial assessment.
I recommend the first port of call for any unwell health professional should be their GP. Many doctors by-pass the system by “corridor conversations” with specialists, but these are risky as GPs offer the best comprehensive initial assessment. It is important a health professional registers with a GP they do not know too well in other areas of their life because this allows the freedom to be a regular patient who can speak openly. If a health professional has a potential recurring psychological illness or addiction it is also worth considering choosing a GP who is known to have a special interest in treating health professionals (such as a GP who has completed the RCGP Health for Health Professionals training, or one with a local reputation for this work).
Another vital source of advice is an Occupational Health Physician.
Another vital source of advice is an Occupational Health Physician. They are immensely helpful, especially by providing an objective evidence based assessment, and guiding rehabilitation, including achieving a timely, phased and sustainable return to work, and in my opinion it is unforgivable that GPs in some regions do not have access to such expertise.
There is a panoply of specialist services offering assessment, treatment and support to doctors and other health professionals.
Finally, there is a panoply of specialist services offering assessment, treatment and support to doctors and other health professionals. For example, these include NHS services such as the Practitioner Health Programme in London, MedNet in London, and House Concern in the North East of England, telephone support and advice lines such as the BMA Counselling Service and Doctors Advisory Service, excellent peer support organisations such as Doctors Support Network and British Doctors and Dentists Group, and organisations offering financial assistance to those in hardship. I have provided a separate resource document detailing all these services (plus many more) and how to access them.
Health professionals can manage their stress using a variety of straightforward techniques, which either reduce the demands experienced by them, or increase their capacity to deal with these demands. Although reducing stress can decrease the likelihood of suffering psychological distress, nevertheless mental illness and addictions are very common in doctors and other health professionals. If you find yourself or a colleague in this situation, I have offered clear guidance on how to quickly access effective help, and to reap the benefits of the excellent outcomes enjoyed by health professionals who seek appropriate treatment.
- Zubin, J. and Spring, B. (1977) Vulnerability: A new view of schizophrenia, Journal of Abnormal Psychology, 86, 103-126
- Covey, S.R. (2004) The 7 Habits of Highly Successful People. Simon and Schuster
- Allen, D. (2002) Getting Things Done: How to achieve stress-free productivity. Piatkus
- Chambers, R., Schwartz, A. and Boath, E. (2002) Beating Stress in the NHS. Radcliffe
- Sotile, W.M. and Sotile, M.O. (2001) The Resilient Physician: Effective emotional management for doctors and their medical organisations. American Medical Association
- Williams, C. (2012) Overcoming Anxiety, Stress and Panic: A five areas approach. Hodder Arnold
- Fennell, M (1999) Overcoming Low Self-esteem: Self-help guide using cognitive behavioural techniques. Robinson
- http://moodgym.anu.edu.au/welcome (Free online programme to learn CBT skills for preventing and coping with low mood.)
Click here to download a PDF document with helpful resources including:
- Specialist assessment and treatment services per region
- National services providing support and guidance
- Helpful books on building resilience and managing stress for health professionals and managers
- Recommended CBT self-help books
Last article of the series to follow soon:
Dr Rhona Knight will describe a pioneering training for GPs wishing to develop their competencies in caring for doctors and other health professionals.