Burnout and Crazy Cat Ladies

Image by Rakka via Flickr

Question: What do professional burnout for nurses and crazy cat ladies have in common?

Answer: Pathological altruism.

This, according to a recent NYT book review “The Pathological Altruist Gives Till Someone Hurts.” (Natalie Angier, 10-3-11). The book is an anthology entitled Pathological Altruism  (Barbara Oakley, et al, editors/ Oxford University Press) due out December 2011. Altruism—behavior aimed at helping another person. True altruism is said to spring from empathy (vs. self-interested egoism). Authors included in this book link pathological altruism to animal hoarding, anorexia, personality disorders, codependency, and professional burnout for health professionals—especially nurses.

Barbara Oakley seems to have gotten the idea for this anthology while she was researching and writing her somewhat creepy (among other things—a cover photo of a black-widow spider), cumbersomely titled book Cold-Blooded Kindness: Neuroquirks of a Codependent Killer, or Just Give Me a Shot at Loving You, Dear, and Other Reflections on Loving That Hurts (Prometheus Books, 2011). A pseudo-scholarly take-off on Capote’s In Cold Blood, her book examines the story of Carole Alden, a Utah artist who killed her husband in what she claims was self-defense/Battered Woman’s Syndrome—but who was sentenced to 15 years for manslaughter. A collector of animals (and of drug-addicted men), Carole was known for her compassion.

But Oakley contends that Caroles’ type of compassion is an example of diseases of caring, of empathy gone awry. She quotes research by Jean Decety, a University of Chicago scientist who examines the neural pathways that underlie empathy. According to Decety, empathy has four components. Empathy is a mixture of all four, and if any one of them gets distorted—by genetics, developmental issues, or stress—empathy can become pathological. Decety’s four elements of empathy are:

1)   ability to share someone else’s emotions

2)   awareness of yourself and other people—and knowledge of where you “end” and where others begin

3)   the mental flexibility to set your own perspective aside and view things from another person’s perspective

4)   the ability to consciously control your emotions. (as quoted pg 57 Cold-Blooded Kindness)

Empathy can either lead to compassion/acts of kindness, or it can lead to empathic distress when the suffering of others becomes or compounds our own suffering. Empathic distress is something that nurses are particularly prone to, leading to burnout. There are empathy brain cells (of course!) called mirror neurons located in the right frontoparietal lobe—in left-handed people. And they’ve identified this area as being active when health care professionals are able to emotionally distance themselves from images and sounds of a patient’s pain and suffering. Researchers are looking at ways of teaching health care providers to be able to emotionally distance themselves “just enough” to protect themselves, while still providing compassionate care. A different kind of Universal Precautions.

In the NYT article referenced above, Angier writes, “Train nurses to be highly empathetic, and, yes, their patients will love them. But studies show that empathetic nurses burn out and leave the profession more quickly than do their peers who remain aloof.”

We know that educating nurses to be aloof Nurse Ratcheds isn’t the answer to burnout prevention. I think that a lot of what is called burnout in nurses is really moral distress: wanting to do the right thing by a patient, but being blocked by factors in the health care system that are outside the nurse’s control. And for prevention of real burnout in nurses, I think we can do a better job in nursing education—by helping students (and ourselves) examine and process the sometimes complex and unsavory motivations for ‘doing’ nursing. Otherwise we will continue to graduate burnout-to-be nurses, along with future crazy cat ladies (and lads).

Cultivating Empathy

Three Way Mirror
Image via Wikipedia

I’m continuing on my line of thought from my last post “On Reflection,” and have been considering how reflective practice and its counterpart of empathy can be taught in nursing school. How can we do a better job of helping students grow in emotional and moral maturity? How can we as health care providers and teachers do a better job of growing in our emotional and moral maturity?

Maura Spiegel who teaches in the Columbia University Narrative Medicine program gave a talk “Reconceptionalizing Empathy” last fall at the Narrative Medicine workshop I attended. She maintains that empathy cannot be taught, it can only be cultivated, and that a common mistake for health care providers in thinking about empathy is the idea that “I can know you—or that empathy can be a conduit into a patient’s inner life.”  The psychoanalyst Donnel Stern maintains that empathy is an interpretation like any other observation, and that empathy is often implicit knowing or “pre-reflective unconscious, an unthought known:” a dimension of experience which is in some sense known, but not yet available to reflective thought or verbalization.”

Metaphor, poetry and art speak directly to our implicit knowing—they are, in Maura’s words, “mediated sources of understanding.” In health care, this is where narrative medicine and the medical humanities step in. Attentively watching movies, reading novels or poetry—or writing and reading our own stories—can tap into the sources of empathy. Language can become an ally again, and the experience of empathy can be made available for reflection. Making more room in nursing curricula for narrative medicine/nursing would be one way to help cultivate empathy in students—and perhaps even in faculty members.

Being able to access empathy and then to reflect on the experience are important skills for nurses. Certain patients or health care situations will affect us more than others. It is easier to have empathy for patients we assess as being “like us” in whatever aspects. Patients, groups or populations viewed as “the other,” are more difficult to have empathy for.

I recently read a collection of essays called The Other by Ryszard Kapuscinski (Verso, 2008). Over his long career as a journalist, he traveled throughout the developing world, reporting on major wars and revolutions. Kapuscinski was influenced in his thought by the philosopher Levinas, who is known for the phrase, “the self is only possible through the recognition of the Other.” Kapuscinski extends that thought by writing, “…the Other is a looking glass in which I see myself, and in which I am observed—it is a mirror that unmasks and exposes me, something we would prefer to avoid.”

Whenever we talk about “The Other” or “Othering” in nursing education, it is almost always in the context of working with patients and groups from “other cultures” or who have stigmatizing conditions such as schizophrenia. We don’t do a very good job at helping students to use their own inevitable discomfort in looking in that mirror to see what is reflected back, to see what is exposed. Sometimes these sorts of issues get handled by students in reflective journals in their clinical rotations, and sometimes it gets discussed in small group seminars—but those times are very few and almost seem to happen by accident. They aren’t explicitly cultivated. One of the problems that I see is that nursing faculty aren’t very comfortable in looking in the mirror themselves, so they aren’t able to model that for students. Encounter Groups for nursing faculty sound like a horror movie in the making, and continuing education conferences on how to cultivate empathy are close behind in the shudder index. One promising change may be that the next generation of nurse educators will be—well—younger, and perhaps more widely educated, more well-traveled, and further along on the emotional and moral maturity scale. That’s my hope.