Psychiatric Annals

Some Factors Involved in Occupation-Related Depression Among Psychiatrists

Judd Marmor, MD

Abstract

1. Marmor J: The feeling of superiority: An occupational hazard In the practice of psychotherapy. Am J Psychiatry 1953; 1 10:370-376.

2. Blaerily PH, et al: Suicide in professional groups, N Engl J Metí 1963; 268:1278-1282.

3. DeSote DE, et al: Suicide and role strain among physicians, im J Sac Psychiatry 1969; 15:294-301.

4. Craig AG. Pitts FN .Ir: Suicide by physicians. Diseases of the Nervous System 1968:29:763-772.

5. Freeman W: Psychiairisrs who kill themselves: A study in suicide. Am J Psychiatry 1967; 124:846-847.

6. Steppacher RC. Mausner JS: Suicide in male and female physicians. JA MA 1974; 228:323-328.

7. Bergman J : The suicide rate among psychiatrists revisited. Suicide ami LifeThreatening Behavior 1979;9:219-226.

8. Duffy J. Litio E: The Emotional Health of Physicians. Springfield. Illinois. Charles C Thomas Pub. 1967.

9. Menninger K: What are the goats of psychiatric education? Bull Mvnninger Clin 1952; 16: ISJ- 158.

10. Shaltow D. et ai: Recommended graduate training program in clinical psychology. Am Psychol 1947; 2;539-558.

1 1. Marmor J:Sexual acting-out inpsychotherapy. Am J Psychiatry 1972:32:38.

12. Pearson MM: Psychiatric treatment of 250 physicians. Psychiatric Annais 1982: 12:194-206,

13. Bittker TE: Reaching out to the depressed physician. JAMA 1976: 236:1713-1716.

14. Marmor J: Psychiatry 1976 - The continuing revolution. APA presidential address. Am J Psychiatry 1976; 133:7. 739-745.…

About 30 years ago I wrote a paper entitled "The Feeling of Superiority: An Occupational Hazard in the Practice of Psychotherapy."' In it, the point was made that the constant exercise of authority carries with it an occupational hazard of creating unrealistic feelings of superiority in the authority figure, and it was suggested that psychiatrists in particular need to be on guard against the tendency toward developing such feelings because of the relative isolation of their work and the transference idealization to which they are often exposed in the course of their practice.

In this article without in any way minimizing the relevance of all of the biopsychosocial factors that play a role in depressive illness, I will look at the otherside of the coin, namely, the possibility that some of the same unique stresses in the practice of psychiatry that create the occupational hazard of an inflated ego, may, under other circumstances, predispose the members of the psychiatric profession to the development of feelings of inadequacy, despondency, and depression.

A number of studies in recent decades have suggested that physicians in general, and psychiatrists in particular, seem to be prone to an abnormally high suicide rate.2"6 These studies indicate that the rate among psychiatrists may be higher than that of any other medical specialty. For example, DeSoIe, Singer and Aronson found that the suicide rate for psychiatrists was 59 per hundred thousand, a rate considerably higher than existed in any other medical group. The next closest rate was that for general practitioners, which was 34 per hundred thousand.

However, Bergman,' in a recent extensive review of the literature about the suicide rate among psychiatrists, came to the conclusion that, if statistical and methodological problems were accounted for, this higher rate was open to question. Among the methodological problems to which he called attention was the fact that most of the prior studies in this area were based on small research samplings, inappropriate comparisons of a small number in one specialty to a small number in another, and inadequate controls for age and sex. Also, translating findings from a small sample to rates per hundred thousand carried a danger of gross misinterpretation. In a very small sample a chance difference of one or two suicides can result in a very large difference in the rate of suicide if computed at rates per hundred thousand. The smaller the specialty the greater the potential, for such sampling errors. Despite Bergman's caveats, it is undeniably true that psychiatrists, like physicians in general, do qualify as a high-risk group for depression and suicide, because they tend to be predominantly older, predominantly male, and predominantly white. In addition, they have high divorce rates and live in urban areas. All of these are factors that accentuate the risk of suicide. Thus, whether the suicide rate among psychiatrists is or is not much higher than that of other physicians, h remains a source of concern that the incidence of both suicide and depression tends to be high in a specialty whose members are dedicated specifically to the alleviation of mental and emotional distress in others.

The tendency in the past has been to explain this finding by the hypothesis that physicians who select the specialty of psychiatry are unconsciously searching for answers to their inner problems in their choice of occupation, and are therefore more apt to be emotionally disturbed to begin with than are members of other medical specialties.

This may or may not be so. However, in what follows, the alternative possibility is explored that, regardless of whatever internal intrapsychic problems psychiatrists bring to their profession, there are. in addition to the stresses faced by physicians in general, unique stresses inherent in the specialty of psychiatry that predispose its practitioners to depressive disorders and their consequences.

Physicians constitute a highly select group. Less than one percent of all college graduates become doctors, and less than 0. 1 of one percent become psychiatrists. As Duffy and LiUn* have pointed out in their study of emotional health among physicians, physicians occupy a social role in which they are expected to adjust well not only to their own inner needs but also to the demands of society. They are expected to be selfeffacing and idealistic. For example, in contrast to other professions, the efforts of physicians to seek economic security are often regarded as unseemly fora group that, in the view of a large segment of the public, ought to be dedicated primarily to serving and servicing the needs of others. Added to this, the functional role of psychiatrists is such that unusually high expectations are placed on them by patients, friends, family and the public at large. Karl Menninger" has listed some of the qualities that are expected of psychiatrists. Among them are integrity, intelligence, sensitivity, dedication, decency, broad interests, and a sense of social responsibility. In a similar but more detailed vein, Shakow '"lists attributes such as superior intelligence, originality, versatility, curiosity, a sense of humor, sensitivity, absence of arrogance, interest in people, ability to relate to them with warmth; also tact, integrity, stability, good ethical values, cultural breadth, and the acceptance of responsibility. Obviously the world expects psychiatrists to be superhuman beings! As I pointed out in I953,' patients and nonpatients alike, by virtue of these expectations, tend to endow the psychiatrist with almost god-like qualities. The assumption that the psychiatrist can read people's thoughts, understand everything, and presumably know how to handle every kind of situation is part of this fabric of excessive expectation. Psychiatrists are not supposed to have any personal problems with which they cannot deal; their marriages are expected to be perfect, their children beyond reproach, and their personal lives are expected to operate at an optimal level at all times.

The gap between such expectations and the realities of our all too human capacities creates a high degree of what sociologists call "role strain." Role strain occurs when there are gaps between expectations and performances, between promise and delivery, between the demands of a profession and the norms of human behavior. Even the families of psychiatrists are no sanctuary from these expectations which are implicitly, if not explicitly, held by their spouses and other relatives. In short, the social role of psychiatrists demands that they function at a maximum and extraordinary level of competence, not just professionally but at all times and in all contexts, including their interpersonal and family relationships. This creates an inordinate occupational role stress for members of the profession. When the defenses against such stresses break down there is a strong tendency for depressive reactions to develop in a context of feelings of inadequacy, loss of self-esteem, and introjected anger.

Role strain among psychiatrists is intensified further by the fact that psychiatry is a specialty in which the treatments are for the most part nonspecific and favorable therapeutic results are often long in coming and difficult to obtain. The expectation that psychiatrists ought to "cure" all of their patients still is widespread even among psychiatrists themselves, although such an expectation does not exist in other areas of medicine. Internists are not expected to "cure" the diseased hearts, kidneys, or livers of their patients. They are considered to be performing adequately if they maintain such patients in a reasonable degree of comfort and equilibrium. Psychiatrists, however, are supposed to achieve optimal results with ail of their patients, and any psychiatric expatient who continues to manifest problems is regarded as a therapeutic failure. Ironically, even when an excellent therapeutic result is obtained with some patients, other people in their interpersonal sphere, who previously had been content with the old neurotic patterns, may then complain about the changes that have taken place! Thus, controlling parents may be unhappy with their child's developing autonomy, or a domineering husband with his wife's newfound assertiveness. As a final ironic paradox, when patients do well and are discharged as relatively "cured." both the ethics and the therapeutic realities of our work demand that we give the lion's share of the credit to the patients themselves, rather than to ourselves. Thus even the successful psychiatrist is denied the ego-enhancing effects available to surgeons or internists who can indulge in the gratification of openly claiming to have been responsible for the cures. In fact, we cannot even admit we've treated the patient, unless the patient chooses to reveal that fact himself.

A third factor in the practice of psychiatry is that patient-therapist relationships in psychiatry are generally more prolonged and intense than in most other professions. Strong transference-countertransference relationships tend to develop with patients who, because of their emotional difficulties, may be either inordinately dependent, seductive and idealizing, or hostile, distant, and distrustful. Such reactions create heavy and ongoing stresses in the course of psychotherapeutic work. Not only the seductiveness of patients, however, but as pointed out elsewhere," specific factors in the therapist's personal life, such as marital difficulties, sexual frustrations, or absence of a partner, may dangerously increase the therapist's vulnerability. Moreover, because of the long-term and meaningful relationships that are developed with their patients in the course of therapy, psychotherapists go through a recurrent "trauma" of separation and loss when such relationships terminate. In contrast to other specialties of medicine where doctorpatient relationships often develop into gratifying personal relationships, the ethical standards of psychiatry generally tend to inhibit the transformation of therapeutic relationships into personal ones.

An additional source of stress is that psychiatrists, like most other professionals, are under strong pressure to maintain an ongoing competence. This involves voluminous reading, as well as frequent meetings, conferences, and continuing education seminars. Although similar requirements exist in other medical specialties, the constantly shifting frontiers of our young science and the impreciseness of much of our scientific and professional work impose greater than usual demands upon psychiatrists. The volume of published material in our field is probably far greater than in any other field of medicine. Moreover, our areas of expertise are expected to extend beyond the technical aspects of neurophysiology, psychopharmacology and psychology into broad-ranging peripheral areas such as anthropology, sociology, art, music, etc.

Still another source of stress in psychiatric practice is the economic one. Psychiatry is probably the least lucrative of all the medical specialties. The amount of time that psychiatrists spend with each individual patient, the fact that as a rule their fees depend on the actual amount of time spent with the patient (usually 45 to 50 minutes), and the long working hours that are consequently required to maintain living standards commensurate with that of other medical specialists, are all elements that contribute to the stresses of the psychiatrist's occupation. In recent years, the pressures of growing paperwork in filling out insurance forms, has added still another straw to the camel's back. Superimposed on all of this in the past few decades is the threat to the professional identity and economic security of psychiatrists that is posed by the growing competition from other mental health professionals.

Finally, psychiatrists are supposed to balance all of these demands and expectations with the equally legitimate demands and expectations of their families, spouses, and children. The well-known vignette about the male psychiatrist coming home to his spouse after a long day of listening patiently to the complaints and anxieties of his patients, and then snarling at his wife when she makes a perfectly innocent and valid demand on his time, is illustrative of this point. So much energy, flexibility, and self-control is required of psychiatrists by their practice that often Utile is left over to cope with the legitimate needs of their families. In this context, special note should be made of the unique stresses that are placed on female psychiatrists, who, in addition to all of the previously mentioned professional tensions, have to function as homemakers, mothers, social secretaries, and the like - often a truly heroic burden.

Because psychiatry by its very nature is an altruistic and self-denying profession, people who go into it are often less capable of expressing aggression toward others, and have a greater tendency to blame themselves rather than their environment or their circumstances when things go wrong. Duffy and Litin8 found that the largest percentage of disorders in their series of doctors with emotional difficulties were the affective disorders. These disorders in physicians are two or three times as frequent as any other variety of major emotional disorder. It seems clear that this vulnerability to depression arises out of the conflict between physicians' needs for emotional support and reassurance as to their competence and worthiness and the excessive expectations of the outside world. The demands of the strict superego which most of us possess contribute an additional dimension to this uneasy equilibrium. This conflict creates a precarious balance that is easily upset by excessive inner or outer demands on the one hand or by a loss of support on the other.

Furthermore, as we know, drug addictions and alcoholism also are often closely linked to depressive disorders. ': Psychiatrists, like other physicians, have relatively easy access to drugs- the temptation for them to use hypnotics, tranquilizers, and /or stimulants is great when the stresses of their lives create excessive tension. The psychiatrisfs need to be constantly alert in listening to their patients and the tendency toward chronic fatigue among psychiatrists due to long hours of such listening, often predispose them to the use of stimulants (to stay alert), as well as the subsequent use of hypnotics (to get to sleep). A vicious cycle results. Alcohol, in particular, becomes an easy outlet and defense against the depressive anxiety and tension that the psychiatrist may develop at the end of a long and hard day. Dependency on alcohol then often develops, with a constant depressive tendency lurking beneath the surface.

What then can the psychiatrist do to neutralize or minimize some of these stresses? Some precepts worth bearing in mind are:

* Try to allow for a breathing space between patients. Many psychiatrists, in the interest of making their time as productive as possible, see patients back-to-back at 45minute intervals without providing an opportunity for time to make a phone call, to dictate some notes, to take care of physiologic needs, or even to step out of the office for a few moments to take a breath of fresh air. This is unwise. There was some wisdom to the original 50-minute hour idea, that allowed for at least a 10-minute break, between each patient.

* It is extremely important to maintain a balance between recreation and work. This, of course, is a basic tenet for reducing stress in any area of work, but is particularly important for psychiatrists, who work long and isolated hours in their offices.

* An effort should be made always to break up the tedium and isolation of long hours in one's office, either by taking a part-time job or doing volunteer work outside of the office in a hospital or clinic. Not only is such activity a break from the stress of seeing one patient after another, but it contributes new dimensions to the psychiatrist's life. In the hospital or clinic one usually sees different kinds of patients, but more than that, it allows for feedback and exchanges with colleagues, psychiatric residents, and other staff people that broaden one's horizons and enrich one's life.

* One should not get so involved in professional activity that sight is lost of the special importance of family relationships and the emotional support system that they can provide. To do so almost always creates personal tensions in family life that place an immense additional burden on the stresses of professional practice.

* It is particularly important that, as psychiatrists, wê do not introject the unrealistic expectations that society has for us, that would make it impossible for us to seek help if and when we begin to feel a need for such help. As Bittker' has noted, "The guilt associated with receiving nurturance from others and the shame provoked by feelings of being weak and needing help" often stand in the way of the depressed physician being able to seek professional assistance. These factors of guilt, shame and false pride are particularly apt to be operative in the case of psychiatrists, whose superegos demand of them that they be above such emotional weaknesses.

In conclusion, the reader should not be left with the impression that the profession of psychiatry is nothing but a burden. Although it has, indeed, been called the "impossible profession," the practice of psychiatry has many emotional gratifications and can be a uniquely enriching and growth-promoting career. As stated elsewhere,'4 there are few endeavors more rewarding, not in the sense of material gain, but in personal enrichment. It is a profession that gives one not just the precious privilege of helping other human beings in distress, but also of learning, in the process, from each of them, so that emotional growth and vistas of human understanding and compassion become progressively enhanced with each passing year. However, there are stresses unique to the practice of psychiatry that predispose psychiatrists to the development of affective disorders. The traditional explanation of this predisposition is based on the fact that members of the profession are presumably more emotionally disturbed than other professionals. This premise does our specialty a grave injustice.

REFERENCES

1. Marmor J: The feeling of superiority: An occupational hazard In the practice of psychotherapy. Am J Psychiatry 1953; 1 10:370-376.

2. Blaerily PH, et al: Suicide in professional groups, N Engl J Metí 1963; 268:1278-1282.

3. DeSote DE, et al: Suicide and role strain among physicians, im J Sac Psychiatry 1969; 15:294-301.

4. Craig AG. Pitts FN .Ir: Suicide by physicians. Diseases of the Nervous System 1968:29:763-772.

5. Freeman W: Psychiairisrs who kill themselves: A study in suicide. Am J Psychiatry 1967; 124:846-847.

6. Steppacher RC. Mausner JS: Suicide in male and female physicians. JA MA 1974; 228:323-328.

7. Bergman J : The suicide rate among psychiatrists revisited. Suicide ami LifeThreatening Behavior 1979;9:219-226.

8. Duffy J. Litio E: The Emotional Health of Physicians. Springfield. Illinois. Charles C Thomas Pub. 1967.

9. Menninger K: What are the goats of psychiatric education? Bull Mvnninger Clin 1952; 16: ISJ- 158.

10. Shaltow D. et ai: Recommended graduate training program in clinical psychology. Am Psychol 1947; 2;539-558.

1 1. Marmor J:Sexual acting-out inpsychotherapy. Am J Psychiatry 1972:32:38.

12. Pearson MM: Psychiatric treatment of 250 physicians. Psychiatric Annais 1982: 12:194-206,

13. Bittker TE: Reaching out to the depressed physician. JAMA 1976: 236:1713-1716.

14. Marmor J: Psychiatry 1976 - The continuing revolution. APA presidential address. Am J Psychiatry 1976; 133:7. 739-745.

10.3928/0048-5713-19821001-06

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