1. ©2012 MFMER | slide-1 Burnout in Overseas Workers Understanding and Managing Stress and Depression JWRichardson 11/8/12

2. ©2012 MFMER | slide-2 Outline Burnout definition Missionary Stress and Burnout- epidimiology Stress and Missionary Personality Burnout prevention Missionary Care Resources

3. ©2012 MFMER | slide-3 “I’d rather burn out than rust out” Is this God’s will for us? (Acts 20:24) “I do not account my life of any value nor as precious to myself, if only I may accomplish my course and the ministry which I received from the Lord Jesus, to testify to the gospel of the grace of God” We do want our lives to be useful and productive for the Lord!! We abhor sloth!!

4. ©2012 MFMER | slide-4 Burnout: what is it? Mechanical definition =“what happens to an electric motor to prevent it from running too long at too high a speed”- shuts down for a while. A preservation phenomenon- does not significantly damage the motor.The motor can run again soon. If this is our definition, then burnout may be OK and scriptural=Self-sacrificial living. Wendell Friest -Taiwan Mission Quarterly, 1996

5. ©2012 MFMER | slide-5 Burnout- Health Definition from “rocket science” COMPLETELY EXPENDED output>input chronically Not a physiological preservation phenomenon Can damage the individual (and others) for a long time. Can prevent an individual from “completing the task God has given us” Can take years to recover, May leave lifelong vulnerability Wendell Friest -Taiwan Mission Quarterly, 1996

6. ©2012 MFMER | slide-6 Missionary/Medical Workers Stress Seldom do we admire and encourage those who maintain a margin of energy and time. Seldom do we admire and encourage those who define healthy boundaries for themselves and their families. We tend to reward chronic self-destructive behavior?? ( as long as it serves our purposes and is not “overt” like suicide, cutting, immorality, drug use, temper tantrums………) Wendell Friest -Taiwan Mission Quarterly, 1996

7. ©2012 MFMER | slide-7 Look at the list of burnout findings and see if this looks like God’s will for his children? Symptoms of burnout- not “rocket science” 1-Negativity/cynicism 2-Loss of enthusiasm 3-Decreased emotional investment 4-Fatigue and irritability 5-Sarcastic humor 6-Withdrawal from co-workers 7-Increased rigidity 8-Feelings of isolation and lack of support Wendell Friest -Taiwan Mission Quarterly, 1996

8. ©2012 MFMER | slide-8 Burnout- “rocket science”- completely out of fuel Symptoms of burnout 9-Easily frustrated 10-Increased sadness 11-Physical ailments/somatization 12-Anhedonia( including sexual) 13-Projection/blaming others 14-Inappropriate guilt 15-”just hanging on” till home assignment 16-Sense of emptiness and depletion Wendell Friest -Taiwan Mission Quarterly, 1996

9. ©2012 MFMER | slide-9 Burnout JWRs experience Restoration may take years The tank does not fill up as easily after being totally drained Hypersensitivity to stress may persist for a very long time Premature return to stressful situation leads to likely relapse and longer restoration the next time JWRs experience

10. ©2012 MFMER | slide-10 Sources of Missionary Stress Dorothy Gish in 1970s 1-Confronting others when necessary 2-Other missionaries 3-Separations, transitions, rootlessness 4-Cultural adjustments 5-Physical stress and risk 6-Spiritual problems 7-Administrative and organizational problems

11. ©2012 MFMER | slide-11 Sources of Missionary Stress Dorothy Gish in 1970s 8-Developmental and accumulated “bruises” and “baggage” 9-Avalanche of Change 10-Choice, choice, choice 11-Not enough “No”s 12-Pretending/Masks- “the search for the real self”

12. ©2012 MFMER | slide-12 Dr. Marjorie Foyle (GB) Medical Missionary for 30 years United Mission to Nepal, then Director(1973-1981) of Nur Manzil Christian Psychiatric Centre (India) which had been founded by E Stanley Jones in 1950, then 23yrs with Interserve visiting 41 countries for missionary mental health Classic Books: Overcoming Missionary Stress by Marjory Foyle, June 1, 1987. Honorably Wounded (updated Missionary Stress) by Marjory F. Foyle, September 1, 2001 nbi press Did her dissertation in her 70s after being a pioneer in studying and providing mental health services for missionaries since the 1970s (51 year missions career)

13. ©2012 MFMER | slide-13 EXPATRIATE MENTAL HEALTH Thesis submitted to the University of London for Degree of Doctor of Medicine, 1999 Marjory F Foyle, MB.BS, FRCPsych, DPM, DRCOG 397 probands prior to and during missionary service Stresses same as per Gish but different rank Adjustment disorders were significantly related to occupational, child-related, home country and acculturation stress, whereas affective disorders were not. Both groups were significantly related to physical ill health

14. ©2012 MFMER | slide-14 Stresses now are much the same as per Gish but different ranking-Foyle 99 1-Occupational stress was #1 in the 1990s 2-Marital 3-Singleness 4-Parental 5-Home country 6-Child-education related 7-Acculturation 8-Re-entry stress

15. ©2012 MFMER | slide-15 Occupational Stress-Foyle 99 The work itself -overload -technical problems -professional isolation Working environment -working conditions Working relationships -leadership (national and expat) -colleagues

16. ©2012 MFMER | slide-16 Marital Stress Dual career families The role of spouses (often wives) Singleness Stress- loneliness Re-entry stress Temporary home leave Permanent re-entry Foyle-99

17. ©2012 MFMER | slide-17 Foyle, M et al. Expatriate Mental Health. Acta Psychiatr Scand 97(4):278-283. Apr 1998 Confirmed that highest risk of major depression among returning missionaries and depression associated morbidity is family history of depression or prior personal history of depression (1999) Missionaries without these risk factors often have adjustment disorder depression.

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24. ©2012 MFMER | slide-24 Stress and Missionary Personality Types- Wendell Friest -Taiwan Mission Quarterly, 1996 Friest Type A(not exactly the tradition A) -self worth based on a sense of achievement -pride vs inferiority -always in a hurry, multi-tasking, overplanning -no matter what I do I never do enough -under some circumstances>> “achievement fatigue” -chronically worried, frustrated, lack of accomplishment, recognition, satisfaction

25. ©2012 MFMER | slide-25 Stress and Missionary Personality Types- Wendell Friest -Taiwan Mission Quarterly, 1996 Friest Type B (not the traditional B) - self worth based on ability to be always giving and meeting other’s needs -guilt vs goodness, conflict avoidant -never good enough -chronically tired>> anxiety and depression -under some circumstances >>compassion fatigue -frustration and bitterness that our own needs are not being met

26. ©2012 MFMER | slide-26 Stress and Missionary Personality Types- Wendell Friest -Taiwan Mission Quarterly, 1996 Neither personality is “bad”, but risk of problems increases if we do “right things for wrong reasons”, especially if for a long time!! We (other Christians) tend to encourage both of these types to join and take on everything To get things done we tend to go back over and over again to these folks who seldom say “No”

27. ©2012 MFMER | slide-27 Major Depression DSM IV Lifetime risk depending on family history and exposure to adversity Sig: E. Caps S- Sleep I- Interest G- inappropriate Guilt E- Energy changes C- Concentration A- Appetitive changes P- Psychomotor changes S-Suicidal thoughts

28. ©2012 MFMER | slide-28 “Subsyndromal” Depression DSM IV based on research criteria Dysthymia- chronic, significant, Double depression- Dysthymia plus MDD Many people have “significant” depression that does not meet Dysthymia of DSM Christians may somatize depression All respond somewhat to multimodal treatment (bio/psyc/soc/spirit)

29. ©2012 MFMER | slide-29 The lifetime risk of major depression among Americans is 17 percent, with as many as 10 percent suffering from depression in any 1-year period. Manag Care. 2004 Jun;13(6 Suppl Depression):9-1 Prevalence and economic effects of depression. Bloom BS. Evidence suggests that high levels of lifetime exposure to adversity are causally implicated in the onset of depressive and anxiety disorders Arch Gen Psychiatry. 2004 May;61(5):481-8. S tress burden and the lifetime incidence of psychiatric disorder in young adults: racial and ethnic contrasts.Turner RJ, Lloyd DA.

30. ©2012 MFMER | slide-30 The familial nature of major depressive disorder (MDD) has been documented in numerous family studies,with a 2-fold increased risk of MDD in the first-degree relatives of depressed patients as compared with controls.(3-fold increased risk of MDD in children with parent with MDD) There were high rates of psychiatric disorders, particularly anxiety disorders, in the grandchildren with 2 generations of major depression, with 59.2% of these grandchildren (mean age, 12 years) already having a psychiatric disorder. Families at High and Low Risk for Depression A 3- Generation Study Weissman, Myrna, et. Al. Arch Gen Psychiatry. 2005;62:29-36.

31. ©2012 MFMER | slide-31 Preventing Burnout Common sense approach: remember that we are FINITE HUMAN BEINGS: CREATED to need exercise, fellowship, food, God, relationship, rest, sleep, work….. Recognize that we are fallible, will make mistakes, will “blow it” AND EVERYONE ELSE NO MATTER WHAT THEY LOOK LIKE IS HUMAN

32. ©2012 MFMER | slide-32 Preventing Burnout-Friest Start with “Who am I” Martin Luther “A Christian is a perfectly free lord of all, subject to none” “A Christian is a perfectly dutiful servant of all, subject to all” Jesus was both the Son of God and Suffering Servant (MT 11:19 and Mark 10:45)

33. ©2012 MFMER | slide-33 Preventing Burnout-Friest “A Christian is a perfectly free lord of all, subject to none” Move from slave modality into daughter-son modality. (Gal 4:4-7) Type A- free from achievement-based acceptance Type B- released from Messiah mentality

34. ©2012 MFMER | slide-34 Preventing Burnout-Friest “A Christian is a perfectly dutiful servant of all, subject to all” Get back into the slave modality without losing the child modality>>Joy and Peace “Slave II” modality= we freely choose to be Gods slave willingly.(Not something God does)>> freedom from self Something we eagerly do (not a SHOULD), not something God demands (Jesus Philippians 2:6,7)

35. ©2012 MFMER | slide-35 Preventing Burnout-Friest “Real freedom is the right kind of slavery” The Paradox of the Gospel = -free to be unimportant -free to not be recognized -free not to have to “succeed” -free to try and not worry about failure (Success or failure is the Masters problem)

36. ©2012 MFMER | slide-36 Preventing Burnout-Friest Identify with Jesus as both a child and slave of God the Father -enjoy without guilt -serve without drivenness or compulsion -serve without need for achievement or recognition Meet our deepest needs in relationship with God and not in achievement or giving to others

37. ©2012 MFMER | slide-37 O’Donnels’CHOPPSS model for missionary care TYPES OF MEMBER CARE SERVICES NEEDED Prevention Development Support Restoration S Culture T Human R Organizational E Physical S Psychological S Support O Spiritual R S Third Dimension: Mission Level Being Assessed ( Individual, Family, Team, department, Base, Region, Agency)

38. ©2012 MFMER | slide-38 Mission Commission of the World Evangelical Alliance http://www.globalmembercare.com/ www.missionarycare.com excellent e-brochures http://www.missiology.org/ http://www.missionsandmarriages.org/ http://www.missionresources.com/missionarycare.ht ml http://www.nlm.nih.gov/medlineplus/depression.html http://www.nlm.nih.gov/medlineplus/anxiety.html http://www.nlm.nih.gov/medlineplus/stress.html

39. ©2012 MFMER | slide-39 Paper Resources Andrews,L Ed The Family in mission: Understanding and Caring for Those Who Serve. Missionary Training International 2004 Foyle, Marjory F Honorably Wounded (updated Missionary Stress) September 1, 2001 emis books (US), Monarch Books (GB) Gish, D. (1983). Sources of missionary stress. Journal of Psychology and Theology, 15, 238-242. Jordan, P. ReEntry, Making the Transition from Missions to Life at Home, YWAM,1992 Lloyd-Jones, D.M. (1965). Spiritual depression: Its causes and cure. Grand Rapids: Wm. B. Eerdmans. Maslach, C. (1982). Burnout - the cost of caring. New York: Prentice Hall Press. Miersma, P. (1993). Understanding missionary stress from the perspective of a combat-related stress theory. Journal of Psychology and Theology, 21, 93-101.

40. ©2012 MFMER | slide-40 Paper Resources Minirth, F., Hawkins, D., Meier, P., & Thurman, C. (1990). Before burnout: Balanced living for busy people. Chicago: Moody Press. O'Donnell, ed. K Missionary Care: Counting the Cost for World Evangelization,, William Carey Library,1992 Pollack, D. Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Cultures. Nbi press 2001 Powell, J. Bowers, J. Enhancing Missionary Vitality: Mental Health Professionals Serving Global Mission. MTI 2002 Powell, J. (1976). Fully human, fully alive: a new life through a new vision. Chicago: Tabor Publishing. Schubert, Esther (1993). What missionaries need to know about burnout and depression. New Castle, IN: Olive Branch Publications Center. Taylor, W. Too Valuable to Lose: Exploring the Causes and Cures of Missionary Attrition, William Carey Library, 1997

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42. ©2012 MFMER | slide-42 I feel burned out from my work I have become more callous toward people since I took this job

43. ©2012 MFMER | slide-43 Physician Burnout Update Burnout is a state of physical, emotional, and mental exhaustion. It results from intenseinvolvement with people over long periods of time in situations that are emotionallydemanding (1). You know you are at risk of burnout if any of the following apply to you (1,2): Emotional Exhaustion: You feel emotionally drained from your work and become increasingly more frustrated and irritated when reacting to routine demands from patients and colleagues. And routine time off from work no longer rejuvenates you. Impaired Cognitive Functions: Memory, concentration, and attention start to lapse, especially during the later stages of a demanding workday. To compensate, rigidly rely on over- learned ways of thinking and behaving. The Resilient Physician Newsletter Wayne M. Sotile, Ph.D. and Mary O. Sotile, M.A. Co Editors-in-Chief www.TheResilientPhysician.com Copyright © W. & M. Sotile, 2003 Used with permissionwww.TheResilientPhysician.com

44. ©2012 MFMER | slide-44 Depersonalization: Your work seems to have hardened you emotionally or made you more callous toward others. It’s as though you are losing compassion for patients and colleagues. Diminished Sense of Personal Accomplishment: Questions about whether your work really makes a difference haunt you, and you lose passion and motivation for work. Impaired Performance: Work-related mistakes increase in frequency. Physical Wear-Down: Your body starts to show signs of wear and tear as your stress related physical symptoms increase.

45. ©2012 MFMER | slide-45 Emotional Distress Spreads: -Increasingly, you take work-related frustration home, where your irritability, worry, or anger at the end of a workday contaminates your home life. Soon, both home and work are affected by your overt or covert expressions of resentment, and you feel misunderstood in both arenas. Organizational Distress: As your negative moods affect those around you, incidences of complaints regarding inappropriate workplace behaviors rise, staff morale dips, and recruitment and retention of key employees becomes difficult.

46. ©2012 MFMER | slide-46 How Big a Problem? By the late 1990's, approximately 37% of physicians were less satisfied than they were as recently as five years prior (3). A 2002 study by Robert Boudreau of the University of Lethbridge and colleagues surveyed 1161 Alberta physicians and found that 48.6% were in the advanced stages of burnout. By comparison, 31% of Alberta nurses and 32% of U.S. physicians are in advanced stages of burnout (4). The costs of burnout are formidable, including physical, attitudinal, emotional, and organizational problems (5).

47. ©2012 MFMER | slide-47 The Burnout Antidote: Effective Emotional Management Research suggests that three things lessen levels of physician burnout (5-7): -Physicians’ advancing age and length of career more control -When physicians are given more control over their practice environment -When physicians are able to influence their own happiness through personal management. In an effort to promote the third of these variables, we developed our effective emotional management (or EEM) model for resilience (8). EEM entails managing personality-based stress reactions and the interpersonal consequences that come with your coping habits. Here are several EEM strategies that can help to either prevent or ameliorate burnout.

48. ©2012 MFMER | slide-48 Be Honest About Your Risk. Beware if you are excessively perfectionistic, if you have difficulty relaxing until all your work is done and all responsibilities are met, and/or if you find yourself in a high- demand/low-control environment. This combination of factors may complicate your efforts to intersperse periods of working hard with periods of rejuvenating recess. Our work in this area suggests strongly that it is not the number of hours worked, but the failure to manage emotions and relationships (both of which take time away from work) that most affect the burnout syndrome

49. ©2012 MFMER | slide-49 Check Your Attitude. Try to find renewed meaning in the daily aspects of practicing medicine. This requires that you balance your achievements and your expectations. Remind yourself regularly why you entered the profession, and fight to keep your behaviors aligned as closely to your values as possible. At the same time, realistically adjust your expectations. Like it or not, every profession is going through upheaval today. If you worked in another setting or profession, the demands you would face would be different, but they would remain substantial

50. ©2012 MFMER | slide-50 Learn to feel good about that which you are able to accomplish, and help your patients, colleagues, and loved ones to do the same. And develop philosophies that remind you that all of your work will never be done and you will never be able to please every patient and colleague. Remember that death is not an enemy, but a welcomed friend and relief to many who suffer. Know that every successful person often “fails,” and that resilience is about continuing to try. Beware the myths taught in medical training that only patients, not providers have feelings, suffer insecurities, and need support

51. ©2012 MFMER | slide-51 Disrupt the “Dominoes” Think of each of the symptoms of burnout as being a single domino in a continuous stack. The key to EEM is to disrupt any one of the “dominoes” with healthy choices. The sooner in the coping progression that you substitute healthy self-nurturing for damaging self-neglect, the better. The main risk to avoid is staying emotionally “numb,” and plowing onward.

52. ©2012 MFMER | slide-52 Take Responsibility for How You Communicate Stress tends to make narcissists of us all. Pay particular attention if you find yourself thinking in terms of “problem” patients or “bad” relationships in your personal life. The antidote? Consider that the meaning of your communication is the response that you are getting. When others fail to respond in ways that please you, consider changing your style, rather than blaming them and waiting for them to accommodate you

53. ©2012 MFMER | slide-53 Protect Your Family Relationships A healthy family life is key to staying resilient. In a recent survey of chairs of OBGYN departments, a supportive spouse or partner was crucial for preventing burnout (9).

54. ©2012 MFMER | slide-54 Respect Your Own Mind/Body/Spirit Between one-fourth and one-half of all physicians do not seek regular medical care (10). Don’t forget the basics: You will either suffer from or be blessed by the consequences of how you treat your body. Regularly engage in healthy pleasures. Only by regularly practicing taking recess without mind-altering substances will you eventually learn to relax without feeling guilty. Modulate times of work and worry with pockets of loving connection with others. Embrace a belief in something bigger than yourself. Be it your god, your family, your profession, or your love of nature, regularly partake of rituals that connect you with those aspects of your life that remind you that there is meaning beyond your stress.

55. ©2012 MFMER | slide-55 Get Support, and Take Time to Grieve. -When patients are overly demanding, emotionally explosive, blaming, or otherwise irresponsible, physicians suffer. -Many of our physician patients suffer from an accumulation of trauma and disenfranchised grieving. But most of the world would be surprised to know that. In fact, physicians are seldom even consoled, much less counseled as to how to de-compress from such pain. Here’s what you can do to help yourself. -Find a forum in which you can express these “undiscussable” feelings and experiences. -Remember that others will not take seriously your emotions until you do. -Take time to construct and participate in your personal grieving rituals.

56. ©2012 MFMER | slide-56 Be an Ambassador of Collaboration and Collegiality Conflict with peers, administrators, staff, and patients is a primary etiological factor in physician burnout. We firmly believe that as this decade unfolds, the physicians, medical organizations, and medical families who prove to be most resilient will be those who foster a new form of collaboration and collegiality within their organizations and communities.

57. ©2012 MFMER | slide-57 References: 1. Maslach C, et al. Maslach Burnout Inventory Manual. 3rd Edition. Palo Alto, CA: Consulting Psychologists Press, Inc., 1996. 2. Schaufeli WB, Enzmann D. The Burnout Companion to Study and Practice: A Critical Analysis. London: Taylor & Francis, 1998. 3. Chan WS, et al. Radiology. 1995;194(3):649-56. 4. CMA Guide to Physician Health and Well-Being. M. Myers, Editor-in-Chief. Ottawa ON: Canadian Medical Association, 2003, p. 5-6. 5. Campbell DA et al.. Surgery. 2001;130:696-705. 6. Spickard A et al.. JAMA. 2002;288(12):1447-1450. 7. W J of Med July 23, 2002. Entire issue. 8. Sotile WM, Sotile MO. The Resilient Physician. Chicago: AMA Press, 2002. 9. Gabbe SG, et al. Am J Obstet Gynecol. 2002;186:601-12. 10. Gross CP et al. Arch Intern Med. 2000;160:3209-14. Copyright © W. & M. Sotile, 2003