Addressing Burnout: When the Body Says ‘Enough’

Whenever I give talks, I often ask the audience to raise their hands if they have had to seek medical attention. Naturally, many hands go up. I then ask attendees to keep their hands raised if their provider asks about early childhood adversities, workplace conditions, their relationship with supervisors, any recent challenges at work, overall job satisfaction, degree of loneliness, quality of life, time spent in nature, experiences, joy, anger, current stressors, etc. In a room packed with hundreds of people, the number of hands remaining elevated dropped significantly. Despite this, those unasked questions are the same reasons many people seek medical expertise.

I ask the audience, “When you have an inflammation of the skin and seek care from a dermatologist, what do they give you?” A steroid, they answer.

“What if you have an inflammation of a joint and you seek care from a rheumatologist?” Again, a steroid.

“What about an internist for an inflammation in your gut?” A steroid, they continue to say.

What is a steroid? A steroid is a stress hormone. When will we connect the dots and realize that stress is the driving force of all autoimmune diseases?

All autoimmune diseases are characterized by inflammation of the affected tissue, organ, or body part. This explains why health care providers often begin with anti-inflammatory drugs such as ibuprofen. When proven ineffective, they resort to steroids. If neither anti-inflammatory drugs nor steroids are deemed adequate, they resort to prescribing medications to suppress the body’s immune activity.

In his famous book, The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture, Dr. Gabor Maté states, “The more we learn, the more we realize that our health is a complex consequence of all our relations.”¹ These relations include our work, relations to our children, relations to our supervisor, to our board members, and to ourselves. Maté continues to say, “Disease is an outcome of generations of suffering, of social conditions, of cultural conditioning, of child trauma, of physiology bearing the brunt of people’s stressors and emotional histories, all interactions with the physical and psychological environments.”¹ In other words, disease is a normal response to abnormality. Disease is the body’s way of saying enough is enough. Disease is a natural response to work-related stress. Disease is a normal process to societal abnormal circumstances.

Cancer is a great example of the incendiary role of stress in the body. We know for a fact that when it comes to breast cancer cells, all women have breast cancer cells without these cells ever developing disease or cancer. We also know that our body’s defense system is always good at harboring malignant cells. The question worth asking then is what drives the progression of these cells into illness? What keeps the immune system from successfully confronting the internal threat?

Here is why. In a state of chronic stress, the body produces a pro-inflammatory cytokine. These cytokines inactivate genes that would normally suppress tumor growth, enable chemical messengers to support the growth and survival of tumor cells, suppress the immune system, and support the branching of blood vessels that bring nutrients to the tumor cells. In other words, cancer is not a disease of individual cells gone rogue, but a manifestation of an imbalanced environment.

In the words of Dr. Steve Cole, “If you get disease, [as a process], a whole series of things had to have gone wrong. Some of that may be related to your genes; some of that may be related to pathogen exposure. Some of it is related to hard lives—the way that can wear and tear on the body and on what would otherwise be resilient tissues. It’s better to think of it as a multistep causation…One of the things many diseases have in common is inflammation, acting as kind of a fertilizer for the development of illness. We’ve discovered that when people feel threatened, insecure—especially over an extended period of time—our bodies are programmed to turn on inflammatory genes.”²

Finding after finding from credible research is suggesting that inflammation risk may be influenced by exposure to stressful life conditions that throw our neurochemical and hormones out of balance. A recent study in the Journal of the American Medical Association shows that people with stress-related disorders had significantly higher risk for autoimmune disorder. And those who were treated for their stress-related mental conditions with selective serotonin reuptake inhibitor (SSRI)-type medication showed a lower risk for autoimmune disorders. This concept is eloquently explained in the word of Dr. Gabor Maté:

“To my clinical sensibilities, concerned as I am with how people fall ill and or find healing, such results, mirrored over and over in multiple other studies, do not suggest: they scream for attention. This is further backed by the fact that we are seeing clear connection between stress and trauma as prime drivers of pro-inflammatory cytokines. The disorganization impact of stress hormones on the immune system as a risk for cancer is far from a scientific secret. We have also seen how stress and trauma are prime drivers of inflammation, another central gear in the cancer-causing apparatus.”¹

When Stress at Work Creates Drama at Home

Time and again, research has demonstrated that when caregivers experience burnout at work or are under immense amounts of stress, they are less likely to be patient and attentive to the needs of those in their charge.³ At times, these stressors leave caregivers preoccupied with genuine concerns about relationship issues or economic worries, and thus unable to be physically and emotionally present. In these cases, stress elevates the limited emotions, which impairs the caregiver’s capacity to be calm, responsive, giving, and attuned to the needs of the child. In stressful environments, children are not only more prone to experience less protection from environmental stressors but are also more likely to have stress-inducing encounters with their caregivers.

Because of the primitive nature of brain development and lack of analytical thinking, children can become easily diminished by the mental state of their caregivers. A child internalizes the mental pressure the caregiver brings home and interprets it as deficiency within themself. As a child’s intellectual capabilities are not developed until approximately age 7, they are incapable of discerning a family problem that is not their fault from one involving a perceived failure on their part.

Because they have no alternative to avoiding the stress state, they have no choice but to personalize it or tune out from their body for an adaptative response to calm their nerves. However, what is adaptive soon becomes maladaptive after chronic exposure to the mental state of their caregiver. That “tuning out” soon translates from the home environment to the classroom environment, which negatively impacts the child’s attention span as well as performance.

It is no surprise that in the United States, the diagnosis of ADHD is spreading like wildfire. According to a study conducted by the National Institute of Mental Health in 2017, the prevalence of ADHD among children was at 11% and rising.⁴

The CDC estimates the number of children aged 3 to 17 years ever diagnosed with ADHD to be 6 million, roughly about 10% of the US population. This percentage includes 265,000 children aged 3 to 5 years (2%), 2.4 million children aged 6 to 11 years (10%) and 3.3 million adolescents aged 12 to 17 years (13%). This statistic shows an astonishing 66% increase between 2000 and 2014.⁵

Children who experience adversity take their internalized, shattered world view into their adult lives where, from their perspective, people should not be trusted. Therefore, when mistakes happen in the family, it is critical for the child to know it was not their fault. It is also important for a caregiver to avoid blaming or making a child feel guilty about certain family-related matters, especially when the child already internalizes every existing family problem. When children are blamed, they begin to feel worthless and insignificant.

In the United States, couples are under enormous pressure to meet the demands of the frenetic lifestyle of the 21st century. We are no longer living in communities where couples can get support from friends or extended family members. Because both parents often spend at least 40 hours a week away from their children working, perfect attunement and attachment by the caregiver is almost impossible. In other words, all children in our industrialized society are growing up with some deficiency in ideal parenting. According to Dr. Bruce Perry, an expert in childhood trauma, these children with ADHD often lack sufficient connections with nurturing adults and have a natural resistance to be controlled by people they do not fully trust or feel psychologically safe with.⁶

Children are sensory experts and curious creatures. They question everything that does not feel or look right. For example, they will wonder why Mom has tears streaming down her face, why their parents fight, why they find Dad sleeping on the couch when they wake up, or see Dad hurt Mom physically or with words. When children question these unfortunate family circumstances, they need to be appropriately addressed; however, when their caregivers normalize these unusual behaviors or when the child’s curiosity and feelings are invalidated, belittled, or dismissed, they stop trusting their senses and learn to normalize these behaviors in their adult relationships. Without being able to trust their sensory data, these children grow up struggling to trust their gut feelings, connect to their authentic self and critically read situations.

Health Care Providers are Experiencing Combat-Like Trauma

Throughout the pandemic, overrun hospitals were often referred to as “combat zones” and health care workers as “front line soldiers.” Research shows that those comparisons were probably warranted. As they faced fatigue, death, fear of infection, burnout, and watched as people ignored public health recommendations, health care workers have been experiencing record levels of mental health distress.

It has been said that front line health care workers are experiencing a level of mental health distress compared to what is seen in the soldiers who serve in combat. As a trauma-informed pharmacist who has personally served at the front line in a combat zone, I believe such a comparison is warranted. What health care workers are experiencing is a type of post-traumatic stress disorder (PTSD) called “moral injury,” a feeling of guilt or shame after having participated in an extraordinary high-stress situation that required immediate and often life-or-death decision-making.

Because of the demand and stress, health care providers are more likely to suffer from PTSD than the general population and it’s easy to understand why. Health care providers bear witness to their patients’ suffering and many lack complete control over their work conditions and ability to maintain personal safety. New demands created by COVID-19 are fueling these stress responses—further raising the risk of PTSD.

Leadership Trauma

Leadership Trauma is being forced to perform at a high level – to walk the tightrope – while in terror of the future. Health care leaders face a different kind of trauma brought about by fear of the unknown. One of the classic symptoms of PTSD is flashbacks. In leadership trauma, however, you have a completely different orientation to time. In leadership trauma, you are haunted by things that could happen in the future. Leaders may have flash-forwards—attacks of panic and anxiety about what might happen in the future.

You might argue that most people worry about the future. However, many corporate leaders stake their entire life and happiness on a single outcome, which they promised to everyone to gain their credibility at the job they hold.

Neuroscientists from the University of Colorado at Boulder found that imagining a threat lights up similar regions in the brain as experiencing that threat does. Imagine a barking dog, a furry spider, or another perceived threat, and your brain and body respond much like they would if you experienced the real thing.⁷

Leadership trauma is a state of mind in which executives are expected to stay in it for far too long, too intensively, and it starts to take a toll on their mental state, as stated by Arzhang Kamarei:⁸

“Imagine living with that kind of pressure, day in and day out, for years. Imagine that every once in a while, there is a gust of wind that risks blowing you off that tightrope. Imagine that wind could be in the form of a pandemic, friends or competitors, or any force that competes with your full attention to that tightrope. Get distracted by them and you will fall. But ignore them at your peril, for they may need your focus. Imagine bathing your mind in that kind of stress, 24/7, for years. And then imagine slipping.”

We enter this profession to help, but often don’t know how to help ourselves. Fortunately, there are techniques that can help prevent our emotional brain from sending false alarms.

• Mindfulness, yoga, and pranayama: These techniques are about bringing ourselves to a full awareness of the present moment, to keep us calm and focused when exposed to images, thoughts or sounds that are reminiscent of our past or that are causing distress, and to restore a full ownership of our body, mind, and soul.
• Build a healthy, supportive network: It is extremely hard for a trauma survivor to feel safe in an environment that often judges them for their feelings. Finding a professional, non-judgmental support group can provide a healthy network of people who have similar experiences and are finding health ways to deal with them.
• Movement is medicine: Decades of research have confirmed that exercise is one of the most powerful tools to help with stress. Movement helps with flexibility, balance, and good health, and movement of any sort can help release tension, deepen our breathing, and boost our memory and mood. Moving your body can include anything you like to do, such as kickboxing, running, swimming, and dancing.
• Journaling: Use writing to pour out all of your anger and sadness. You can use a journal to record events and feelings or write a letter to yourself about the ways people made you feel. Express yourself freely and let the energy flow out of you. We usually feel better after we let negative energy out of our system.
• Find a furry friend: We all need a dose of companionship and unconditional love from our pets. Our pets help us reconnect with our community and serve as our companion when no one is around to give us support. Having a pet that needs to be cared for can provide you with a sense of purpose and a reason to get out of bed on those less-than-good days.
• Heal your trauma through creativity: Art, music, and dancing are used around the world to treat trauma, and especially to help people express their suffering. Those who struggle with not being able to articulate their trauma and feelings may be able to express themselves through a creative process, such as art or music.

Long working hours, a lack of resources, the inability to take needed breaks, and the added responsibilities of meeting the demand created by the pandemic are among the challenges that health care providers live with daily. We can’t solve the problem if we can’t prove the problem exists. Telling your stories can help bring about positive change. Some of the necessary changes to address the wellbeing of pharmacists include increasing the number of technicians, reducing the number of working hours, and hiring more pharmacists to meet patients’ demands.

References

1. Maté, Gabor. The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture. Avery, 2022.

2. Social Regulation of Human Gene Expression by Steve Cole & 46 Chromosomes and a Mule by Janina Jeff. TheACMGChannel. Youtube. June 15, 2023. Accessed November 20, 2023. https://www.youtube.com/watch?v=IDjiTxajA40

3. Sahlins, M. The Western Illusion of Human Nature. (Chicago: Prickly Parading Press, 2008). Cited by Narvaez, D. “Are We Losing It? Darwin’s Moral Sense and the Importance of Early Experience,” in The Routledge Handbook of Evolution and Philosophy. Ed. Richard Joyce. New York: Routledge, 2017.

4. Attention-Deficit/Hyperactivity Disorder. National Institute of Mental Health. Reviewed September 2023. Accessed November 20, 2023. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

5. Data and Statistics About ADHD. CDC. Reviewed October 16, 2023. Accessed November 20, 2023. https://www.cdc.gov/ncbddd/adhd/data.html

6. Perry, BD. The Boy Who Was Raised As a Dog. Basic Books, 2017.

7. Reddan MC, Wager TD, Schiller D. Attenuating neural threat expression with imagination. Neuron. 2018;100(4)994-1005. doi:10.1016/j.neuron.2018.10.047

8. Kamarei A. Trauma May Explain the Suffering of CEOs, Leaders, and Startup Founders. Kamarei Advisory. Updated September 19, 2023. Accessed November 20, 2023. https://www.kamareiadvisory.com/post/ldr-trauma