Month: December 2014

On the psychologist as ‘collateral damage’

As I creep towards qualification as a clinical psychologist (a week away!), my mind is drifting, understandably, towards life-post-training. As a trainee, most of what you do is guided by your supervisors; although that doesn’t stop entirely once you’re qualified, you do get more liberty to practice as you see fit. Most of us practice in fairly idiosyncratic ways, even if we use specific models or theories as our basis. To my mind, people are different and their problems are never the same, so it makes perfect sense to provide a broad church of interventions.
But there is more to being a clinical psychologist than providing therapy, as any of us will tell you, and, for me, there is more to being a clinical psychologist than my job. We don’t walk out of our offices and cease to be clinicians; nor do we suddenly stop being the people we are during work hours. For it takes something to choose to do work like this: we tend to be interested in others; we are often acutely aware of the impact of emotional distress on people and those around them; we likely have a strong sense of social justice. These things may be more finely-tuned over the course of training but they probably exist in spades before that. It’s hard to turn it off, but, increasingly, I’m wondering how that knocks on to my non-work-work – the work I do that is psychology-related but which is not in my job description. There are obvious things – I would like an academic career; with the result that I spend some of my non-work time writing academic papers for publication. I blog a bit, though that has taken a dip recently. I occasionally write a bit for the press and I’ve started lecturing. In recent months, I’ve spent more time working with other psychology types, working on projects related to the impact of inequality on mental health and the role of my profession in doing more to effect social change. It’s busy, but it’s exciting. Crucially, I am also maintaining a life that is truly ‘non-work’.
I’m brutally aware, however, of how easy it can be to slip into ‘overworking’ mode. I suspect that the sort of person who is happy to go into academia is also the sort of person who might find themselves working sixty-hour weeks. I have spent the past four years being a postgraduate student, which often involves working unconventional hours. Prior to that, I worked shifts, which is about as chaotic as it gets. The truth is that it’s been about six years since I had a ‘normal’ working week. Pleasingly, I have a lot of energy and I work reasonably efficiently. Nevertheless, it’s something I have been thinking about a great deal.
Throughout clinical training, we are encouraged to maintain the ‘work-life’ balance; encouraged to say no to things we can’t do; encouraged to take care of ourselves so that we can take care of others. It doesn’t sound all that easy; it’s even harder to do in practice. It’s easy to slip into working more than necessary to get something done purely because you will feel guilty if you don’t. It’s easy to go to work when you’re unwell because you don’t want your colleagues to have to pick up your work when they’re probably already stretched to the limit. It’s easy to beat yourself up for not doing enough when you are acutely aware of how much there is to be done (the social inequalities stuff I’m doing at the moment, for example, seems directed towards an enormous dragon; one that may well not be slain for quite some time).
One of the therapies offered by some in my profession is schema therapy. I don’t use it myself, since I’m not trained to do so, but the principles of it interest me. Essentially, it suggests that we each have specific ideas about ourselves and our relationships (schemas) that repeat throughout our lives. There are 18 basic schemata, and some evidence suggests that, amongst people in my profession, the self-sacrificing schema is the most common. As you might expect, people with this way of relating to the world tend to focus on meeting the needs of others at their own expense. It makes sense – we tend to work with people whose needs have often not been met by others, whether that be the need for love or acceptance or safety. As a consequence, it’s all too easy to go above and beyond the call of duty. It’s hard to say ‘no’ when colleagues ask if you can take on extra tasks. It’s gratifying when your expertise is recognised and you’re invited to contribute to policy or guidance. And, equally, making this into a career is hard. Some people want to be clinicians who work five days a week and no more. Some have different aspirations and, like all worthwhile things, achieving those aspirations takes work. We’re no strangers to hard work – I have spent ten years working towards qualification and that’s certainly not out of the ordinary.
So what do you have? Well, you might have a profession in which people believe in what they do and want to do it well. You have people who want to do good. You have people who probably have s strong ethical code and who perhaps want to leave some kind of legacy (we’re not immune from liking our egos to be gratified; we’re not superhuman). How easy it is, then, to burn out. That’s not something unique to health professionals, of course, but it’s something we are at significant risk of.

So far so obvious. But then the question we ask less often: is it worth it? If I spend fifteen years working more than I should and in that time I contribute significantly to research, policy implementation and service development, does that mean that the potentially negative effects on my health are offset by the good I have done? Everything has a cost; no benefit comes without a price. In war we talk of ‘collateral damage’ and we seem to have an unspoken agreement that destruction is sometimes necessary and often tolerated. We work towards the ‘greater good’. Surely that logic needs to extend to individuals if we are to avoid being hypocritical? We have killed tens of thousands in wars over the past decade for the sake of some ‘greater good’. Surely, then, the health of a couple of dozen psychologists can be sacrificed in the pursuit of better public health. For that is our business – improving public health, in any way we can.

Now the conundrum comes when we talk about abstract sacrifice and try to apply the principles to personal sacrifice. So, in the abstract, none of us is indispensable, however displeasing that is. We are all mortal; we will all die. Given that, the idea of some of us sacrificing our health or dying as a consequence of putting as much into our work as we can seems like a small price to pay. The greater good, eh?

But. One of the other things psychologists do is take the abstract and bring it down to the personal. Emotions, individual experience, all that stuff. So while in the abstract we can think of self-sacrifice as something which is a means to an end, the truth is that very few of us is comfortable with being the one that burns out, the one who has a stroke in their 40s, the one who dies in what should be their prime. We don’t mind collateral damage as long as we’re not the people who make up the collateral (just like the collateral in war, of course).

The scientist in me (for I do consider myself a scientist)  has a bit of a problem with this, as does the ethical human. Given that I believe in what I do, given that I believe that much of your value as a person is based upon the good you do for others, given that I am fully aware of my mortality and the extremely limited time we all have to do anything of worth, why on earth is it fine for you do work yourself into the ground to achieve something extraordinary but unacceptable for me to do so? Many will take exception to that and state that it is never acceptable for anyone to work themselves into the ground for the sake of psychology or public health; if you’ve read this far, you’ll gather that I question that rather. Or is that just my maladaptive schema talking?

I’m not quite sure what the answer is to all this. I don’t think there’s any great nobility in wrecking your body and mind for the sake of your job, but, then, this isn’t about a job, per se – it’s about helping to make a society which views and treats people with mental health problems differently. Nevertheless, my suspicion is that working to a degree which damages you is likely to result in your colleagues pitying you and wondering why you can’t do yourself that which we try to help our patients to do – to avoid trying to be superhuman. Many of the people who come to see me end up there because they simply tried to do too much and, eventually, they reached their limit. The comparison is not lost upon me. But then, I’ve always said it – there is little that differentiates me from my patients, aside from the fact that we sit on different sides of the consulting room. Essentially, we’re all the same – humans, with our flaws and our egos and our need to do or be something or someone out of the ordinary, though our reasons may be different. Ultimately, whether as professional or patient, we are, as I am so fond of saying, all in mental health services.