Burnout in Overseas Workers
Understanding and Managing Stress and Depression
JWRichardson 11/8/12
©2012 MFMER | slide-1
Outline
• Burnout definition
• Missionary Stress and Burnout- epidimiology
• Stress and Missionary Personality
• Burnout prevention
• Missionary Care
• Resources
©2012 MFMER | slide-2
“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!!
©2012 MFMER | slide-3
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
©2012 MFMER | slide-4
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
©2012 MFMER | slide-5
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
©2012 MFMER | slide-6
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
©2012 MFMER | slide-7
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
©2012 MFMER | slide-8
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
©2012 MFMER | slide-9
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
©2012 MFMER | slide-10
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”
©2012 MFMER | slide-11
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)
©2012 MFMER | slide-12
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
©2012 MFMER | slide-13
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
©2012 MFMER | slide-14
Occupational Stress-Foyle 99
The work itself
-overload
-technical problems
-professional isolation
Working environment
-working conditions
Working relationships
-leadership (national and expat)
-colleagues
©2012 MFMER | slide-15
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
©2012 MFMER | slide-16
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.
©2012 MFMER | slide-17
©2012 MFMER | slide-18
©2012 MFMER | slide-19
©2012 MFMER | slide-20
©2012 MFMER | slide-21
©2012 MFMER | slide-22
©2012 MFMER | slide-23
Stress and Missionary Personality TypesWendell 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
©2012 MFMER | slide-24
Stress and Missionary Personality TypesWendell 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
©2012 MFMER | slide-25
Stress and Missionary Personality TypesWendell 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”
©2012 MFMER | slide-26
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
©2012 MFMER | slide-27
“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)
©2012 MFMER | slide-28
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 disordersArch
Gen Psychiatry. 2004 May;61(5):481-8.
Stress burden and the lifetime incidence of psychiatric disorder
in young adults: racial and ethnic contrasts.Turner RJ, Lloyd
DA.
©2012 MFMER | slide-29
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 3Generation Study Weissman, Myrna, et. Al. Arch Gen
Psychiatry. 2005;62:29-36.
©2012 MFMER | slide-30
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
©2012 MFMER | slide-31
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)
©2012 MFMER | slide-32
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
©2012 MFMER | slide-33
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)
©2012 MFMER | slide-34
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)
©2012 MFMER | slide-35
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
©2012 MFMER | slide-36
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)
©2012 MFMER | slide-37
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
©2012 MFMER | slide-38
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.
©2012 MFMER | slide-39
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
©2012 MFMER | slide-40
©2012 MFMER | slide-41
I feel burned out
from my work
I have become
more callous
toward people
since I took this
job
©2012 MFMER | slide-42
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 permission
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 overlearned ways of thinking and behaving.
©2012 MFMER | slide-43
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.
©2012 MFMER | slide-44
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.
©2012 MFMER | slide-45
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).
©2012 MFMER | slide-46
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
-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.
©2012 MFMER | slide-47
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 highdemand/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
©2012 MFMER | slide-48
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
©2012 MFMER | slide-49
• 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
©2012 MFMER | slide-50
• 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.
©2012 MFMER | slide-51
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
©2012 MFMER | slide-52
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).
©2012 MFMER | slide-53
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.
©2012 MFMER | slide-54
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.
©2012 MFMER | slide-55
• 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.
©2012 MFMER | slide-56
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
©2012 MFMER | slide-57