Defence and pretence
Tuesday, 23 January 2018
VetScript Editor's pick - December 2017
Organisational and health sociologist Andrew Dickson of Massey University’s School of Management examines how veterinarians cope – or don’t cope – with the daily emotional juggling act of the role, and suggests how the profession could mitigate the resulting stress.
When I took our beautiful Labradoodle in for his last veterinary visit, I wasn’t in a great frame of mind.
He was 14 years old, a glorious age for a glorious dog. He’d spent the last few months doing pretty well, despite having stage four lymphoma. But things took a turn for the worse and we knew it was time.
I didn’t know the veterinarian on duty that day very well. We had only lived in the town for a couple of years, and the veterinary practice is a really big one with lots of employees and I’d met this one only once or twice before. It didn’t take long to complete the procedure, but I was broken emotionally.
I was at the clinic for about an hour that day. The veterinarian called me Graham the whole time (my name is Andrew!), and kept referring to our male dog as ‘her’. Little things in the grand scheme of things, and I didn’t say anything, and I didn’t really care. But I did think about how difficult it must be for these poor clinicians, accompanying the human companions of their patients. Dealing with people who are emotionally broken, crippled by the loss of something as special as the bond with a dog. I wondered then if the seeming disconnection from the little details of my life was a functional way to defend against the trauma of having to bear witness to my pain.
The mental health of veterinarians - beyond stress?
It is becoming well established in the literature that veterinarians report suffering mental health symptoms such as depression and anxiety more than their equivalents in the general population, although they are also “highly satisfied in their work” and generally “perceive a net benefit to their wellbeing” (Cake et al., 2015). But in the most serious cases, the ramifications of mental suffering can result in suicide – and veterinarians sadly are over-represented in this statistic, too. The reasons for this are multiple and complicated, and care needs to be taken not to over-simplify.
The common reasons given for mental suffering in veterinarians all circulate around ‘stress’. Here is where simplification can be problematic, because someone becoming stressed often involves many things over a long period of time. Stress is an insidious thing; it tends to creep up on a person, often registering first as frustration, defensiveness or disconnection.
Much of the writing on stress in veterinary medicine talks about compassion fatigue. This would be the typical way to describe how my veterinarian went about the business of treating my old dog. For a scholar of the psychosocial like me, compassion fatigue is a very troubling concept. Take the following definition, for instance, drawn from the counselling sector: “The natural behaviour and emotion resulting from knowing about a traumatising event experienced by another, compassion fatigue is the stress resulting from helping or wanting to help a traumatised or suffering person” (Fox, 2003).
In the context of the veterinary profession, the stress of compassion fatigue builds slowly over time. But from a psychosocial perspective, it is the unresolved juxtapositions through daily practice that are the most problematic.
As Katherine Dobbs put it in an article for the American Veterinary Medical Association, “We are the only profession that walks from a euthanasia with a family we’ve known for years to another room with a new puppy, and we have to be all smiles” (Nolen, 2011).
What does it take for a person to pull off this act? What does it take to produce two sets of totally contrasting emotional states within the same effective time period? The answer here for most people is defence and pretence. We need to defend against the anxiety that comes from the trauma in the first case in order to be present for the second. The pretence then involves establishing the appearance of feeling (“all smiles”) as a performance, regardless of what is going on underneath.
There are actually a number of other professions that have to deal with significant juxtapositions in their daily activities: social workers, counsellors, psychologists and psychotherapists, for instance. All of these professions have at their core continuing therapeutic care – group and/or individual supervision and group and/or individual therapy.
They are able to regularly discharge or debrief with trained others who understand. With this support, the clinician can be present with both situations, death and new life, the horror of a patient dealing with the loss of her mother followed immediately by a patient who is quietly falling in love.
The problem, of course, is that the organisational structures and cultures of most therapeutic professions are set up for this; they have limited consultations in a day, and time and money put aside for continuing therapeutic care. What is the situation in the veterinary sector?
How can a workplace help?
The factors that veterinarians identify as issues in terms of mental health broadly revolve around poor working conditions, including isolation, long working hours, taxing work, lack of support and the resulting stress that comes from this.
It is not uncommon for new veterinary graduates to find themselves on call throughout the night without the easy backup of a senior colleague, or to be one of only a couple of veterinarians running a practice in an isolated rural community.
In organisations that are large enough, it is likely that there will be support structures in place – access to senior clinicians for consultations any time of the day and employee assistance programmes, for instance. They will also be geared up for working with the realities of managing people, dealing with absenteeism, allowing employees who are not coping to take time off, and managing excessive workloads. In small practices these may be more difficult, but not impossible.
But for me these basic systems are just a first step; the next is establishing a culture of supervision as the very basis for organisational models. This would take seriously Gardner and Hini’s suggestion that veterinary practice managers develop “procedures for debriefing staff after particularly stressful experiences” (Gardner and Hini, 2006).
However, if we take this a step further, rather than wait until the fateful “stressful
experience”, excellent practice would view the whole profession in organizational terms and invest in the psychotherapeutic equivalent of supervision. This bears a resemblance to what is commonly referred to in organisational theory as mentoring, but there is a significant difference. Whereas mentors tend to place significance on the performance and the careers of mentees, supervision pays close attention to mental wellbeing – it is concerned with how the person is coping with the particular stressors of the work.
“Effective supervisors have empathy, offer support, flexibility, instruction, knowledge, interest in supervision, good tracking of supervisees, and are interpretative, respectful, focused and practical” (Kilminster and Jolly, 2000).
Ideally, this would be built directly into the fabric of the veterinary profession, accessible to all veterinarians, always.
This is a significant challenge, as it would involve the training of existing veterinary practitioners in counselling and the establishment of supervision relationships while new veterinarians are still in training – relationships that persist throughout one’s career, regardless of which organisational structure is doing the employing. But the benefits are significant, as it can provide a structure that is independent of but complementary to specific organisational practices.
Bartram DJ, Yadegarfar G, Baldwin DS. A cross-sectional study of mental health and wellbeing and their associations in the UK veterinary profession. Social Psychiatry and PsychiatricEpidemiology, 44(12), 1075, 2009
Brannick EM, DeWilde CA, Frey E, Gluckman TL, Keen JL, Larsen MR, Helke KL. Taking stock and making strides toward wellness in the veterinary workplace. Journal of the American Veterinary Medical Association 247(7), 739–42, 2015
Cake MA, Bell MA, Bickley N, Bartram, DJ. The life of meaning: a model of the positive contributions to well-being from veterinary work. Journal of Veterinary Medical Education 42(3), 184–93, 2015
Cohen SP. Compassion fatigue and the veterinary health team. Veterinary Clinics: Small Animal Practice, 37(1), 123–34, 2007
Fox R. Traumaphobia: confronting personal and professional anxiety. Psychoanalytic Social Work, 10(1), 43–55, 2003
Gardner DH, Hini D. Work-related stress in the veterinary profession in New Zealand. New Zealand Veterinary Journal, 54(3), 119–24, 2006
Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Medical Education, 34(10), 827–40, 2000
Niehoff BP, Chenoweth P, Rutti R. Mentoring within the veterinary medical profession: veterinarians’ experiences as protégés in mentoring relationships. Journal of Veterinary Medical Education, 32(2), 264–71, 2005
Nolen RS. Ignoring compassion fatigue can be bad for business. www.avma.org/News/JAVMANews/ Pages/110615q.aspx AVMA website, 2011