The crisis of stress

Dealing with stress and burnout in caring professions

Winton H. Beaven, Ph.D., is dean emeritus of Kettering College of Medical Arts.

Stress is a fact of life. You are under stress when you drive to work, when you are late to work, when you receive unexpected company, when you chair a meeting, when your pet dies. Happiness, sadness, pain, trauma, cold, heat, worry, all produce the same symptoms of stress within the body. Stress affects all age levels. You may experience nausea, have a sudden headache, start to perspire, have an increased heart rate, feel tightening of the muscles in your back or around your forehead, burst into tears, or bite your nails. During stress your body works to readjust itself to normal functioning.

The relationship of stress to physical and mental health is a comparatively recent discovery and is ongoing. Hans Selye, the "father" of stress medicine, developed and popularized the term stress in 1946.1 According to Selye, "stress is the nonspecific response of the body to any demand made on it."2

Stress-producing factors

Stress-producing factors are called "stressors." They can be the desire to win a game, the necessity to perform well in a public place, or sympathizing with a person suffering great loss. They are all different, but they all elicit essentially the same biological response. Conceptualizing stress in biological terms, Selye developed the theory of general adaptation syndrome (GAS). GAS encompasses three stages: the alarm reaction, in which the body reacts to the stressor; resistance or adaptation; and exhaustion, when adaptation is lost.

Stress also has a psychological nature. It is a response state, the intensity of which is determined by individual perception and interpretation. People respond differently to the same stressors. A traffic jam may mildly irritate one person and completely traumatize another. The point to note is that the amount of stress cannot be determined by examining the stressors alone. The context in which the stress occurs and the previous experience of the individuals affected are also important. Furthermore, the threat of stress may produce the same effects as the stressor itself.

Stress is often associated with the unpleasant in life. This can lead to the view that if we avoid stressful situations, we will be better off. And indeed, in cases of severe stress with a known cause the temporary flight from this stress may be a necessary therapeutic approach. However, one cannot successfully flee from stress; that is achieved only with death.

Manage or burnout

The bottom line is: we must manage stress, or else burn out. Burnout occurs when our adaptive energy is gone. Selye theorized that each of us has a reservoir of adaptive energy from which we can withdraw, but there is no proof we can also make deposits.3 We can squander our resources or we can learn to make this resource last by using it sparingly in worth while causes---if possible, in those that cause the least distress.

Symptoms of burnout vary, but there is a common core: loss of concern, loss of feeling, a feeling of detachment, a tendency to treat others in a dehumanized way. All this may end in a feeling of utter hopelessness.

How do we cope with stresses and avoid burnout? Of all the characteristics that humans have and animals do not, the one that stands out most is our ability to do something about our condition. "Learn to ignore what you can't control and learn to control what you can," writes Dr. Peter G. Hanson, author of The Joy of Stress, a best-seller. "Take an active role in your own management; do not be just a passive tourist through life."

Our goal, then, is to learn to manage stress so that it is not unduly destructive. But how do we do that?

Health and stress management

Dr. Robert Veninga, coauthor of The Work-Stress Connection, reported that in his research 19 out of 20 sufferers from burnout were physically unfit and were not following a healthful diet or exercising appropriately. The first line of defense against pressure is the confidence that comes from being vibrantly alive, physically and emotionally.

Thinking positively helps in accommodating stress. The most cheerful characters in any group of people are those who deal with life's tribulations most effectively. A cheerful mind can turn stress into a positive force.

A third ingredient in good stress management is spiritual health. Just as physical health requires a regimen of exercise and good health practices, so too, spiritual health requires regular study, devotions, and personal prayer.

Stress and helping professions

Anyone can burn out; it is not in and of itself an indication of personal weakness. Certain professions, however, seem to be more dangerous than others. These jobs can be called stress carriers and produce a higher level of stress than others. Note worthy in this regard are all the helping professions. Pastors, physicians, counselors, teachers, nurses, social workers, and other similar caregivers are in this category. In addition, workers in heavily bureaucratic organizations and managers/ executives in general have high levels of stress. Finally, women in the world of work have special problems unique in degree to their gender roles.

We shall focus on caregiver burnout. However, the prevention and treatment principles apply to any professional or work situation. In high levels of burnout stress we often face the problem of diagnosis. Most burnout symptoms are so generalized that pinpointing cause can be frustrating. In addition, there is no test with an established high validity that is very helpful. For emotional illness, several accepted diagnostic tests are available. No such tests have yet been developed for burnout. However, I have found two self-diagnostic instruments to be useful in preliminary diagnosis. The first and simplest self-instrument was developed by Ayala Pines and Elliot Aronson.4 The second, slightly more comprehensive, appears in Beverly Potter's work. In diagnosis, of course, there is no good substitute for a skillful physician.

Coping with burnout

How, then, do we learn to cope effectively with stress in our lives, to prevent burnout or recover from burnout? The key word is coping! Coping refers to efforts to master conditions of harm or threat when an automatic response is not readily available.5 It is a continuous process with no foreseeable end. It focuses on dealing with chronic stresses inherent in everyday life.

Richard Lazarus6 has been a leader in stress research. In the course of his research he created a coping grid. This grid summarizes all the possible actions one can take in dealing with severe stress. It looks like this:

(table from p. 11 from May 1996)

To illustrate the application of the grid, let us assume that the source of the stress is a very difficult boss. What am I going to do about my high stress level precipitated by a paranoid boss? In looking at the grid, I choose "direct action." I try to change the boss. If this doesn't appear to be a good strategy, I can confront the boss. If either or both of these courses are unsuccessful, I can adopt an attitude that says that there are so many good features of my job that I'll develop a positive attitude toward the boss and live with the situation. This is direct coping strategy. It is applied externally to the environmental source of the stress.

Instead of a direct active strategy, I could choose an indirect active strategy, that is, a strategy applied internally to my behavior and emotions. I conclude that the effectiveness of attempting to confront or change the boss is a problematic choice. Thus I might join groups of other unhappy depart mental colleagues in criticizing "the chief." I participate in this frequently. I try to change my own behavior to reduce friction by involving myself in activity away from my direct workplace.

As time goes on say, a period of three years I come to the conclusion that I could not change the working conditions so that they are bearable. I slowly slide into the direct inactive mode. I avoid the department chair, and at the end of three years I resign. I do not adopt the indirect inactive choice, which is obviously destructive and futile.

The grid can be applied to any high-stress situation in which the source of stress is known and capable of confrontation/ change.

Which strategy to adopt?

Is one strategy better than another so that one could generalize successfully? Hard data is scarce, but research reported by Ayala Pines and Elliot Aronson indicates: "that active strategies were used most often to cope with burnout and were reported most successful. Inactive strategies were used less frequently and were reported least successful: the more frequent the use of active strategies, the less burnout; the more frequent the use of inactive strategies, the more burnout. An exception to this pattern was the direct inactive action of ignoring the source; this action was found more similar to the active strategies than to the passive ones."7

One should not assume that in every case a particular coping strategy is most effective. On the contrary, every situation tends to have some uniqueness, and people may behave in accordance with their own temperament patterns in such a way as to make generalization hazardous. The best coping is done on a case-to-case basis, not by a formula approach.

Social support

Social support is another effective strategy. Social support is "information leading subjects to believe that they are cared for, loved, esteemed, and valued and that they belong to a net work of support."8 Research indicates that social support helps is effective in prevention of as well as in recovery from burnout.

What does social support provide?

The first need met by human supporters is "hand-holding." Everyone needs one or more people who will actively listen to them without giving advice or making judgments. People need to be able to share joy and pain, success or failure, with a human being. Occasionally, under stress, people need to be able to "blow their tops" in a safe environment where a good listener is understanding and sympathetic.

Second, those in professional life in general, and in care-giving in particular, need to have people who can appreciate what they do from a knowledgeable point of view and under stand the technical demands their work lays upon them. Most ministers, for example, are solo performers: one pastor, one church or church district. It is likely that there is no one avail able to give expert, honest feedback on their performance. To provide technical support, the individual must be competent in the field and have integrity enough to be trusted. That person's technical appreciation becomes a significant validation of the pastor's ministry.

These two services performed by competent and trusted colleagues can be differentiated by a simple anatomical contrast. When we are doing well, we need someone to validate our efforts by a pat on the back. When we have gone stale, we need someone to apply more vigorous pressure about 18 inches lower on the back. Support or challenge!

Total personal support

Occasionally we need more than listening and hand-holding. We need a kind of support that can be called total personal support regardless of circumstances. In stressful times we need someone who is with us no matter what, who gives us total acceptance without regard to how we are performing.

When we are performing poorly or have "given up," we may need emotional challenge. We may gradually build defense mechanisms that make it difficult for us to evaluate performance objectively. When we have been overcome by emotional stress, we may find it easy to wallow in our misery. At such times we need emotional challenge from someone we can trust.

Lifestyle and burnout

We experience burnout not as the result of a major stressor, but from an accumulation of minor stressors. If that is the case, an examination of one's lifestyle is strongly indicated. If you are suffering high-level stress and have not yet pin pointed adequate cause, you might look at one or more of the following potential problems.

Poor time management is one of the most frequent causes of burnout. If you are continually running behind, you need to annotate every minute of waking time for at least two weeks. Such an exercise will reveal one or more of the following situations:

1. You do not have appropriate time controls on your activities. You do not keep appointments on schedule but continually run over.

2. You do things that you do not schedule and thus repeatedly are off schedule.

3. You do not allot enough time to do what you plan. There are other possible scenarios. Do your two-week diary and diagnose the difficulties. Then plan your strategies for change, enlist the cooperation of spouse, children, and colleagues---and change. After an appropriate period, evaluate, adjust, and continue.

Another frequent problem is realistic goal setting. While attempting the difficult and stretching one's capabilities is laudable, acknowledging one's limitations is absolutely essential to maintain tolerable stress levels.

Strategies to reduce stress

Strategies for reducing stress in care-giving involves development of certain special skills. These skills help the caregiver to survive in an atmosphere that requires dealing semi-continuously with persons who are under high levels of stress.

First, there is detached concern, a term coined by Harold Leif and Renee Fox in the context of medical care. "The empathetic physician is sufficiently detached or objective in his attitudes toward the patient to exercise sound medical judgment and keep his equanimity, yet he also has enough concern for the patient to give him sensitive and understanding care." In this way, "the patient, rather than just his liver, heart, or even psyche, is the concern of the physician."9

"Detached concern" applies not only to physicians but to all caregivers and most particularly to ministers, nurses, and other counselors. It is an attempt to find a middle road between being so concerned with the needs of the counselee that one loses objectivity and becomes less professionally capable, and becoming so self-protective that one has complete detachment and thus becomes dehumanized.

Another protective skill is the ability to separate one's life and work. This is particularly important for a minister, and at the same time extremely difficult. But it can be done! One should have a life outside of work.

Use of decompression techniques is another skill that helps avoid or reduce unduly high stress levels. Decompression is an escape valve involving a general slowdown; a time to be quiet, meditate, exercise, or relax. In high-tension work situations decompression techniques may need to be followed several times a day. The greatest need for decompression is at the end of the workday.

The two hours after work are the hours that pose the greatest domestic hazards caused by job stress; this is especially true in a two-parent working family. The wife comes home to face husband, children, and new role stressors with little relief. The husband comes home seeking a little peace and rest as he peruses the paper. Both greet each other at the door unloading the day or calling each other to home duties with no respite. Home, instead of a haven, becomes a new stress threat.

Some of this can be avoided by accepting the reality and by careful planning to share the burdens and use decompression techniques. You can agree not to deal with family discipline until after the meal. You can agree not to deal with major problems until a measure of quiet and relaxation has been achieved. You can alternate roles---both parents and children---to provide variety and share both stress and relaxation.

In the professional work world a relatively new stress factor has been added in recent years. It is called the power lunch. Working hours are not enough we must work through lunch. If you do this and do not take other "breaks," you have created for yourself a workday without major relief. Remember, our premise is preventing burnout. It is not stress that is the problem; it is unrelieved stress.

"And which of you by being anxious can add one cubit to his span of life?" (Matt. 6:27, RSV).

1. H. Selye, "The General Adaptation Syndrome and the Disease of Adaptation," Journal of Clinical Endocrinology 6 (1947): pp. 117-130.

2. ___, Stress Without Distress (Philadelphia: J. B. Lippincott Company, 1974), pp. 27, 28.

3. Ibid.

4. See A. Pines and E. Aronson, Career Burnout: Causes and Cures (New York: Free Press, 1988).

5. See A. Monat and R. S. Lazarus, Stress and Coping (New York: Columbia University Press, 1976).

6. Ibid.

7. Pines and Aronson, p. 146.

8. S. Cobb, "Social Support as a Moderator of Life Stress," Psychosomatic Medicine 5, No. 38: 300-314.

9. H. I. Lief and R. C. Fox, "Training for 'Detached Concern' in Medical Students," The Psychological Basis of Medical Practice (New York: Harper and Row, 1963),

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Winton H. Beaven, Ph.D., is dean emeritus of Kettering College of Medical Arts.

May 1996

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