Acknowledging mental illness in psychiatrists

The medical anthropologist and general practitioner (GP) Cecil Helman wrote, in his posthumous memoir An Amazing Murmur of the Heart,

As a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment. (Helman, 2014)

There is a lay perception that we often encounter that is often expressed as a question: ‘how do you listen to people complain all day without going mad?’ We tend to dismiss or downplay this, shrugging off such concerns with some glib reference to it being part of the job. Helman’s insight chimes with the perception. The emotional toll of our work is inherent. All our work is trauma work, at some level.

Writing in the British Journal of Psychiatry in 1967, A’Brook, Hailstone, and McLauchlan observed, ‘in view of the important implications of the subject, it is surprising that there have been so few studies of psychiatric illness within the medical profession’. Fifty years on, the mental health of doctors has been extensively studied. Despite there being the medical specialists in mental health, the mental health of psychiatrists specifically has been studied far less so. Psychiatrists show significantly raised mortality overall compared with other doctors (Carpenter, Swerdlow, & Fear, 1997) and have been shown to be more likely than doctors from other specialties to suffer from a range of mental health problems (Firth-Cozens, 2007).

The literature on this topic has tended to assess both individual and systematic factors in psychiatrists becoming mentally unwell. There is a tendency to focus on the individual characteristics of those who wish to become, and ultimately do become, doctors in general and psychiatrists in particular.

It is well recognized that doctors in general are more likely to have some personality traits possibly associated with the onset of mental illness than the general population. Terman’s (1954) study of the life course of ‘gifted’ individuals found that physicians tended to feel inferior, relative to those of comparable attainment in other fields; George Vaillant’s Grant Study of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects (Valliant, Sobowale, & McArthur, 1972). Doctors and medical students have also, in general, found to be high in conscientiousness which is linked to obsessionality (Harries, Kim, & Grant, 2017). Walton and Last (1969) found psychiatrists to be more open and agreeable, although less conscientious and with higher amounts of neurosis and more severe depression.

Teasing out the relationship between propensity to mental illness and the impact of work stress is challenging. Complicating this is the difficulty of differentiating between the elements of work stress which are unavoidable – the emotional impact of what our patients tell us – and those which are, in principle, remediable – the organizational structures and cultures we work within.

Furthermore, there is evidence that personality traits are weak predictors of mental illness in doctors. Brewin and Firth-Cozens administered measures of depression and of dependency and self-criticism to a medical student cohort, measuring depression again at 2-year and 10-year intervals. Self criticism and, to a lesser degree, dependency were significant predictors of depression for male doctors in the first postgraduate year (the 2-year interval), while for female doctors, self-criticism was the only significant predictor. At the 10-year interval, the predictive effects for male doctors were similar albeit weaker, whereas none of the variables predicted depression in female doctors (Brewin & Firth-Cozens, 1997). A focus on psychiatrists’ personality traits may be another way of making the ‘problem’ intrinsic to individuals and allow organizations off the hook.

In the literature, the impact of organizational culture and systemic issues is frequently raised, yet the focus of discussion and of recommendations made is on the individual practitioner. And this consideration of the individual is of the mentally unwell psychiatrist as a management challenge, rather than as a person due compassion and understanding.

For instance, Firth-Cozens does acknowledge the impact of cultural and organizational factors, especially the absence of leadership, but the focus of her recommendations is on factors such as selection into medical school and psychiatric training (Firth-Cozens, 2007). While her paper overall is an extremely valuable contribution to the literature and is clearly grounded in a compassionate approach to this issue, there is also a sense of the psychiatrically unwell psychiatrist being a problem best avoided by not letting the potentially mentally unwell into psychiatry in the first place.

The dislocation mentally unwell psychiatrists face is compounded by their familiarity with both generalities and specifics of treatment and management. They are aware of the mental health legislation, aware of the distancing gaze of professional interactions and aware of the verbal formulas of the multidisciplinary team and the admission note.

Trying to identify what individual factors may predispose a psychiatrist to become mentally unwell is, of course, a worthwhile endeavor. It may allow for targeted, supportive interventions. On occasion, it may even be legitimate to counsel some individuals not to pursue psychiatry as a career. However, we would strongly urge that a focus on individuals in isolation of the work environments we are in would not only miss the point but also further entrench the view that the mentally unwell psychiatrist is an ‘other’, a ‘management problem’ and so on.

There is a distinction to be made between burnout and organizational factors in this context. The term burnout carries with it connotations of something internal to the person. The implication often is that if only the person had had the good sense to look after themselves in some way, they would not have burnt out.

In military psychiatry, it was recognized over the course of the First World War that what was then termed shell shock could affect any soldier and that the duration of exposure to combat was the key factor. Despite a military and official focus on ‘moral fibre’, the realization that even the most motivated, disciplined and trained soldiers would eventually experience sufficient trauma to experience shell shock came slowly (Shepherd, 2002).

There will of course be a percentage of psychiatrists who, even in the most supportive and healthy organizations, will become mentally unwell. This reflects the reality that there will be a percentage of people who, even within the most propitious social and family milieu, will become mentally unwell. Nevertheless, organizational culture has been clearly identified as a major contributor to the development of mental illness among psychiatrists. Let us be clear, the organizations in which we work are failing our colleagues and our selves.

We would respectfully but forcefully suggest that, as the medical specialty dealing with mental health, we should expect more from our own organizations and systems. This is of course not an issue confined to the medical members of the multidisciplinary team, but is of relevance to mentally unwell nurses, psychologists, occupational therapists, social workers, therapists and all the rest of the professions.

Ultimately, naming the reality that psychiatrists can and do become mentally unwell is a necessary step in change. This change needs to focus on the organizational and cultural barriers to help seeking and to acknowledging vulnerability. A system charged with the care of the mental health of others must value and foster the mental health of those who work within it.