Health and wellness

Alcohol Is Not a Health Food

Here’s yet another reason for “Dry January,” if not “dry indefinitely”: US Surgeon General Vivek Murthy says alcohol consumption causes cancer, that it is responsible for 100,000 cases of cancer and 20,000 cancer deaths annually.

“The direct link between alcohol consumption and cancer risk is well-established for at least seven types of cancer including cancers of the breast, colorectum, esophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx), regardless of the type of alcohol (e.g., beer, wine, and spirits) that is consumed. For breast cancer specifically, 16.4% of total breast cancer cases are attributable to alcohol consumption.”

Do we need warning labels on every bottle, as he’s proposing? Setting aside the fact that it won’t happen due to pushback from the alcoholic beverage industry, I think it would probably be a waste of time and money, because it’s not likely to change anyone’s behavior. Most people who drink already know that alcohol can be harmful to the body, because they’ve had one or more harmful experiences, or “negative consequences” as we say in healthcare, and yet they keep drinking anyway. But that’s the cynic in me talking.

The optimist in me says, Yes, even if it only moves the needle 10%, that could save 200 lives! More, given the many ways that drinking can lead to death. While most people don’t heed warning labels, some do, and although it won’t help the folks who are committed to drinking regardless of risk, it may get the attention of those who are concerned about their health and want to increase their chances of living a long and healthy life.

His advisory has already got our attention – I’ve seen half a dozen news articles on the topic in the past week – and talking about it could lead to behavior change. We can’t change that which we are unaware of, so the first step in change is awareness.

If you’re skeptical of this news, that’s not surprising. After all, hasn’t the medical community been telling us for decades that moderate drinking is safe, even a healthy habit?

Here’s what I know, based on my training as a substance abuse counselor, over 40 years of experience counseling adults who drink too much, and my own personal experience. In a nutshell:

* Alcohol is both an intoxicant and a toxin
* Its addictive potential is strong
* In small amounts, it produces some pleasant benefits, like relieving social anxiety and stress
* But it comes with serious risks, including painful illness and death, which are not always proportionate to the amount consumed.
* It is so ubiquitous in our society that if you don’t drink you’re considered odd, and if you do, it’s very easy to consume too much.

How much is too much? That’s a key question. Do you know that before the 1980’s, a standard drink was considered to be 1 oz of spirits, or 4.2 oz of wine? You could get six drinks from one bottle of wine. But drinks, like food, got supersized, so that now the standard drink is 1.5 oz spirits, 12 oz beer and 5 oz wine. Many restaurants offer 6 or 8 oz pours of wine, while craft beers and hard seltzers have a higher alcohol content. Right there you can see how easy it is to overdrink, and how common it’s become. (Here’s a standard drink chart for reference.)

The notion that moderate drinking is healthy originally came from Scandanavian health survey data, which showed a correlation between “moderate” alcohol consumption and low rates of disease. First, correlation is not causation. Moderate drinkers might have good genes, or a healthy lifestyle, or get health checkups more often. Second, it turns out that “moderate” drinkers in those surveys were those who drank “more than none,” anywhere from 1-2 drinks a year up to 1 drink a day. From this data, our American healthcare experts extrapolated that it must be healthier to have a drink a day than none at all!

To be clear, alcohol is not a health food, and there is no universe in which it’s healthier to drink alcohol than to abstain. Doctors who have “prescribed” a drink a day, or assured their patients that “moderate drinking is perfectly safe” are either uninformed, afraid to offend their patients, or in denial about their own alcohol consumption. But we can’t just blame doctors; most people want to believe that 1 to 2 drinks a day is okay.

In reality, for most people most of the time, drinking is a pleasant experience. Alcohol is an effective mood enhancer, at least initially, and it can anesthetize physical pain as well as numb emotional pain. Because it lowers anxiety and inhibitions, it serves as a “social lubricant” for many people. Many people like the taste, and enjoy trying different drinks.

Can something be both good for you and bad? Sure, consider acetominophen (Tylenol). It’s available over the counter, so it must be safe, right? Yes, if you take 325 – 1,000 mg every 4-6 hrs, as the label directs. But wait – just 4,000 mg over 24 hrs can cause liver damage! The same is true of ibuprophen (Advil), which is safe for pain relief if taken as directed, but can destroy your stomach lining if you take it in large quantities. There’s a fine line between a safe amount and a risky amount, just as with alcohol. (And fentanyl, which I had for a recent surgery, but obviously wasn’t given a 12-pack to take home!)

The comparison with fentanyl is more apt than with acetominophen, because of the potential for addiction. Nobody gets addicted to Tylenol. Why? It’s not an intoxicant, it doesn’t give you a buzz or mellow feeling. So understanding the addictive potential of alcohol is also an important factor in deciding whether it’s safe for you to drink.

For many years, people thought it was perfectly safe to smoke cigarettes, and they smoked in restaurants, offices, airplanes, even hospitals! We now know that for many years the tobacco companies spent lots of money to suppress the research that showed smoking causes cancer, and that nicotine is addictive. Now these are well-known facts, and yet, some people still choose to smoke. (Another US Surgeon General warned about smoking and cancer back in 1964, but smoking behavior didn’t change for decades.)

The risks associated with alcohol consumption are also known, and the alcoholic beverage industry has also tried to hide that research, but mostly, it just spends millions of dollars every year on marketing campaigns to convince you that everyone drinks (not true), and that drinking alcohol will make you happier, sexier, and a lot more popular!

These days, it’s a safe bet that most people who drink are drinking too much, and should drink less or quit, for their own good. So why don’t they? The most common reason people have trouble changing their drinking habits is simply that a habit can be difficult to change, especially when there’s so much encouragement for drinking in our society, and when it’s so readily available and relatively inexpensive.

Most people can drive over the speed limit without getting a ticket or having an accident, and we usually don’t even think of that as “risky” behavior. In the same way, we don’t tend to think about drinking as risky, and any negative consequences from drinking may seem so rare or unlikely to happen that they’re easy to dismiss as “it’ll never happen to me.” (By the way, that’s the title of a classic book about children of alcoholics, and ironically, if you have a parent who is or was an alcoholic, your odds of developing alcoholism increase by 50%.)

Another reason some people drink too much is they believe “everyone drinks like this, and that’s just how it is.” They think of drinking as a super fun activity to do with friends, which makes them feel sexy and no longer shy, and so what if they black out or have a terrible hangover the next day, doesn’t everyone? This thinking is common among people who may have started out with binge drinking in high school or college, and don’t know any other way to consume alcohol. (Binge drinking is defined as 5 or more drinks on one occasion.)

I have counseled hundreds of adults who have experienced “negative consequences” (blackouts, DUIs, relationship problems, health issues, job jeopardy) from drinking, and would like to learn how to avoid future negative consequences. None of them have wanted to quit completely, and most didn’t believe they needed to quit, because “I’m not an alcoholic, I just enjoy [the taste, the way it relaxes me, the social aspect]”. So we start with a treatment goal of drinking less, not quitting.

My experience has confirmed what the research shows: indeed, some people can learn to drink less, so that they lower their risks of negative consequences. Usually it’s younger people, who have been drinking for fewer than 10 years, who don’t have a family history of alcoholism. Occasionally it’s an older person who just needed to learn a few tips, like to drink only occasionally, not drink on an empty stomach, alternate alcohol with drinking water, stick to 1 or 2 drinks, and to say a firm “no thanks” to another one.

But most of my clients who have experienced one or more negative consequences from drinking haven’t been successful at moderation. They quit counseling instead, or in some cases, come to the decision that it might actually be easier to abstain completely, because it seems to require too much self-discipline to drink less.

Frankly, one major reason some people continue to drink too much despite negative consequences is that they’re already addicted and just don’t know it, because alcohol use and abuse exist on a spectrum, where the lines between “moderate drinking,” “risky or problem drinking,” and “alcoholism” are difficult to discern. If addiction has already taken hold, chances of learning to drink moderately are slim, no matter how much willpower a person has.

I believe it’s still worth trying to reduce a dependence on alcohol, so I support “Dry January,” and “Sober Curious,” and encourage you to consider other experiments in abstinence. Keep a log or journal of thoughts and feelings that arise when you’re choosing to not drink, and pay attention to what your mind and body tell you – it might be very informative!

If you’d like help figuring out your relationship to alcohol and whether it needs to change, please feel free to reach out to me. I’m not taking new patients for long-term therapy, but I am available for short-term consultation, assessment, and referral. I also recommend checking out the ReThinking Drinking website.

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Living with Loneliness

Loneliness, a normal part of the human condition, has reached epidemic proportions in recent years. Amplified by the social isolation that the COVID pandemic imposed (and continues to demand of the elderly and the immune-compromised), loneliness as a social issue was already on the rise. As I wrote in a 2017 post on social support (1), a national survey revealed that 25% of Americans said they had no one in whom they could confide or share a personal problem. (A similar survey in 1985 had reported that most people had at least 2 – 3 trusted confidants.)

The highest reported rates of loneliness are among seniors, who are more likely to be living alone, retired from the workforce, and needing to protect themselves from the risks of catching not only COVID but all of the other viruses circulating out there. One of the most unfortunate consequences of our modern society, particularly in this country, is the sidelining of elders, who in earlier generations were considered a necessary part of a family, whether as caregivers for grandchildren and keepers of the home fire, or as sources of wisdom and familial history and traditions. Now, many elders are left feeling superflous, invisible, not belonging anywhere.

Right behind seniors in reported rates of loneliness are teens, who are developmentally still learning social interaction rules and skills, and who were hit hard by the closing of schools during the lockdown. Some still have not returned, or have dropped out. Teens lack the perspective that “this too shall pass,” giving more urgency to current distressing circumstances. And they are more reliant on their smart phones and social media, which create a false sense of being connected while not requiring any direct social interaction at all.

And in between are the rest of us, who may be experiencing loneliness for a variety of reasons, and to a greater degree than before. Everyone feels lonely sometimes, but as a recent article in The Atlantic says, “emerging evidence suggests that we are in the midst of a long-term crisis of habitual loneliness, in which relationships were severed and never reestablished.”(2)

According to Vivek Murthy, US Surgeon General, this is a public health issue.(3) Indeed, research has shown that loneliness is a risk factor for several kinds of health problems, including cardiovascular disease and dementia, as well as mental health, especially depression and suicide.(4)

While other nations (Japan,England) have created governmental agencies tasked with finding solutions to loneliness (5) the US has tended to regard it as an individual problem rather than a societal one, leaving Americans to cope with loneliness on their own. Ironic, but not surprising!

So if you are experiencing loneliness, you’re not alone! Know that this is a common condition in today’s world, caused by many factors over which we have little or no control (including the pandemic, political polarization, and over-reliance on smart phones and social media) so you are not to blame. I repeat, it is not your fault.

However, it is up to you to do something about it. The best remedy for loneliness is to reach out to other people – not to ask for help, but rather to offer it, either as a volunteer or a friend. There’s truth to the old adage, “get busy helping others and you’ll soon forget your own troubles.” As I have written previously,

It is easier to give than receive. Most people find it much easier to offer help, than to be the one asking for help. Research on the health benefits of social support shows that while giving support is correlated with health and living longer, receiving support conveys no longevity benefit. Perhaps this is because it’s stressful to ask for help, or because those who receive support are already suffering more ill-effects of stress. (6)

Find something you can do that will force you to get out and interact with other people. Make an effort to be kind and friendly to others. Look for opportunities to interact in person, from taking a walk with a friend to signing up for a class at a senior center or community college. Don’t be afraid to call someone you haven’t spoken to in a while – there’s a good chance that they may also be feeling lonely! And finally, if you’re not already seeing a therapist, consider contacting one. It can help just to talk about it.

NOTES

1. Here’s the blog post I wrote in 2017 on social support, that includes this startling statistic: Social Support – The Survey

2. “How We Learned to be Lonely,” by Arthur C. Brooks, The Atlantic, 1/5/23 (if you can’t access this online, let me know and I can send you a copy of the article from the print edition)

3. “The Pandemic of Loneliness,” article on the California Health Care Foundation website, published 8/2/21

4. “How Loneliness is Damaging Our Health,” by John Leland, New York Times online edition, 4/20/22

5. Vivek Murthy speaking at online international conference on loneliness, sponsored by the UK’s Campaign to End Loneliness (2/8/23)

6. Quote from my second blog post on social support in 2017

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Depression Treatment News

Reported rates of depression have increased dramatically in the last few years, possibly related to the COVID-19 pandemic and its associated stressors, like social isolation (1). However, it seems that many people who report depression symptoms are not getting treatment (2) while others are questioning whether antidepressant medications are as safe and effective as we’ve been told (3). And while there have been some new and promising treatments, they are not widely available due to cost and lack of access. That’s the bad news, in a nutshell.  The good news is that there are many proven effective non-medical alternatives for treating depression. This article will briefly summarize current medical treatments for depression as well as alternative treatment options.

New(ish) medical treatments include Transcranial Magnetic Stimulation (TMS) and Psychedelic-assisted therapy, of which ketamine or Spravato is the most well known. TMS and Spravato have both been approved by the FDA for “treatment-resistant” depression, which simply means depressive symptoms that haven’t responded to conventional treatment with a medication like Prozac or Zoloft, the selective serotonin reuptake inhibitors (SSRIs).

TMS involves having your brain “zapped” by electromagnetic charges. While that may sound scary, it is painless and relatively risk-free, with a fairly good success rate. The downside: it must be administered at a doctor’s office in a series of sessions, usually about 30 over six weeks, and it’s expensive if your insurance plan doesn’t cover it. Recently, researchers at Stanford University School of Medicine have developed a new version that can be completed within five days, which could be a game-changer if it’s approved by the FDA and covered by insurance (4).

Ketamine has been around for a long time. Originally developed as an anesthetic, it became popular as a party drug due to its hallucinogenic properties. Some doctors have been using ketamine infusions on an experimental (“off label”) basis to treat depression, which again is fairly costly and not covered by most insurance plans. I have a few patients in my practice who’ve had this treatment; while one experienced remarkable results, the others did not. In 2019, the FDA approved a nasal spray version of ketamine, Spravato (5). I don’t know anyone who’s used Spravato, so I can’t speak to its effectiveness, but at $3000 to $6000 per month, and with no research on its long-term effects, it’s simply not a viable option for most people. If you’d like to learn more about ketamine treatment for depression, see the notes below for a link to a fairly readable scientific article (6).

Another psychedelic drug currently being studied as a depression treatment is psilocybin, the active ingredient in “magic mushrooms” (7). A recent study found that just 2 doses could relieve depressive symptoms for up to 12 months (8). Psilocybin is classified by the federal government as a controlled substance, and therefore cannot be prescribed by a doctor nor obtained over-the-counter, though a number of states and cities have recently passed legislation to decriminalize it. There’s a lot of money being poured into psilocybin research right now, and many universities have established centers for psychedelic research, so one way to get this treatment may be to join a clinical trial (9).

Meanwhile, as doctors are prescribing more antidepressant medications than ever, others are questioning the efficacy of these medications, and whether their risks outweigh any benefits. A recent analysis in a respected medical journal concluded that “the real-world effect of using antidepressant medications does not continue to improve patients’ health-related quality of life over time.” (10)

We have been taught to believe that SSRIs (selective serotonin reuptake inhibitors) are safe and non-habit forming, so they can be taken indefinitely, and also discontinued easily. This is only partially true. SSRIs do have fewer harmful side effects than the older generation of depression meds. They are not addictive in the same way that opiates or benzodiazepines are, meaning you won’t develop cravings. However, their effects and side effects are definitely not harmless, quitting them abruptly can have negative consequences, and many people have found that even a tapered withdrawal may cause unpleasant effects, which can last for months or years in some cases. A study published in The Lancet, the British medical journal, in 2019 demonstrated that withdrawal from standard antidepressant medications is much more protracted and difficult than most doctors believe. (11)

I just watched a very interesting webinar on Antidepressant Drug Withdrawal Syndrome, which is a real problem for many people, so whether you are on an SSRI, thinking about taking one, or wanting to get off one, you might want to watch it too!

So what can we conclude from all of these studies? First, the mechanisms of how antidepressant medications work are still poorly understood. The theory that depression is caused by a chemical imbalance, specifically a lack of serotonin, has not been scientifically proven, in fact there’s very little evidence for it.

Second, depression is not like getting the flu or strep throat. There’s often no clearly identifiable cause, such as a virus or bacteria that can be tested for. There isn’t a predicatable course of illness. It shows up differently in different people, and even in the same person at different times. There’s debate about whether it should be considered an illness, for these reasons. Maybe it’s just part of the human condition? And third, we need to keep in mind that research on new treatments is usually funded or sponsored by pharmaceutical companies, who routinely sacrifice scientific rigor in their drive to push a new product to market, putting profits before people’s health and well-being.

There are many alternative treatments for depression, most of which are cheaper and have few or no side effects; many have been scientifically proven to be effective. Let’s start with dietary changes. Did you know that 95% of the body’s serotonin is produced in the gut? As Leslie Korn writes in Nutrition Essentials for Mental Health, “the standard American diet, consisting of overly processed foods containing refined sugars, leads to chronic inflammatory states and neurotransmitter imbalances. Inflammation is now understood to underlie most mental illness, including depression. Chronic low-level inflammation contributes to depression and cognitive decline.” (12) Read my blog post about  how dietary changes can improve mood here.

Other effective approaches for treating depression include behavioral changes, especially improving sleep quality and increasing exercise; herbal remedies (St. John’s wort, tryptophan, 5HTP); nutritional supplements (Omega 3 fish oil, vitamin D, and B vitamins, especially folate); self-help groups (the Depression and Bipolar Support Alliance); social support networks, and various forms of psychotherapy, including cognitive-behavioral therapy (CBT and ACT) and of course my favorite, Mindfulness-based Cognitive Therapy (MBCT).  MBCT has been proven to be at least as effective as antidepressant medication in preventing the recurrence of depression (13). 

That’s the real news about depression treatment: if you start with improving sleep, exercise, and nutrition, then add social support, CBT, and mindfulness, it’s possible to achieve better and longer-lasting recovery from depressive symptoms, at least for many people. So rather than keep chasing after that elusive “magic pill” (which I don’t believe exists) doesn’t it make more sense to try some of these alternatives?

NOTES

1. According to the most recent National Survey on Drug Use and Health, taken prior to 2020, depression rates were already rising among teens and young adults
2. Trends in U.S. Depression Prevalence From 2015 to 2020: The Widening Treatment Gap, published in the American Journal of Preventive Medicine, 63(5)
3. Antidepressants Don’t Work the Way Many People Think, by Dana G Smith, New York Times online edition,11/8/22
4. The short timeframe Transcranial Magnetic Stimulation developed at Stanford University School of Medicine, NPR 2/6/22
5. FDA approves Spravato (esketamine), a nasal spray for “treatment-resistant” depression, New York Times online edition 3/5/19
6. A fairly readable scientific article to learn more about Ketamine treatment for depression
7. This is a good overview of Psychedelic-assisted therapy 
8. Recent study on Psilocybin treatment for depression at Johns Hopkins University
9. If you’re interested in How to find Psychedelic therapy, including how to enroll in a clinical trial
10. Analysis concluding that antidepressants don’t improve quality of life
11. The seminal study in The Lancet demonstrating the antidepressant withdrawal syndrome is real 
12. Korn, L (2016) Nutrition Essentials for Mental Health
13. Kuyken, W., et al. (2016). Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials. 

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Back from Burnout

It’s been a while since I’ve written here – let me explain my absence. Early this year I began to recognize the signs of something resembling burnout in myself, and decided to take the advice I often give to my patients, to take a step back from some of my activities and responsibiilities in order to focus more on my well-being. The activities I chose to give up were writing blog posts and newsletters, teaching online mindfulness classes, and taking new patients.

At the time I thought this “break” might last for a month or two, but as it turned out, I needed much longer to heal and restore what was depleted in me. It wasn’t as simple as “get more rest,” nor was it about setting boundaries or saying no to excessive demands on my time. That’s the prescription for typical burnout, but this was a different kind of emotional exhaustion. I practice what I preach about self-care, so I was getting plenty of sleep, regular exercise, and healthy nutrition, and I’ve got good boundaries. Then why was I so exhausted?

I am a “silver lining” person, usually able to find the good or beneficial even in the worst of circumstances, and I had been doing that for the first year of the pandemic, but then it stretched into two (now three) with no clear end in sight. Those first months of the lockdown were hard, but there was a sense of “we’re all in this together” that made it feel more like an adventure. Then when vaccines became available, there was a sense of relief, and hope that this would be over soon. Instead, it got worse, fueled in large part by all of the people who refused to get vaccinated, mostly for reasons that made no sense to me. I no longer felt like we were all in this together.

I am also a person who has always felt a deep connection to Mother Nature, and when my batteries need recharging, I head to the woods, or the ocean, or just my garden. During the lockdown, I was grateful to have a yard and garden, and to live in a neighborhood that’s safe to walk in, where I could access trails into the hills.  I was able to spend more time outdoors, which helped, but it’s also depressing to try to grow things during a prolonged drought, and with all of the extreme weather events (remember that day in August 2020 where the sun never came out, and it felt like we were on Mars?) Forest fires, hurricanes, floods and mudslides –  we are experiencing the harsh reality of what our reliance on fossil fuels has done to the planet, and yet, people aren’t changing their habits, and fossil fuel companies have doubled down.

On a related note, I’d been working hard to maintain my optimism for the benefit of my patients and students, as well as colleagues and friends, all throughout the dark years of the previous administration. But here we are, still living under that dark cloud six years later, with nearly a third of adult Americans still believing the lies about a stolen election and voter fraud. Those lies and the people who promote them threaten the very foundations of our democracy.

As I write that last paragraph I realize I risk losing a few of you as readers, which points to one of the gravest concerns that I have about the world we are living in today: we seem to have lost  the ability to even listen to, let alone respect differing views, opinions and perspectives. That factor alone has affected my motivation to write, because I believe what makes something worth reading is its potential to stimulate thought, challenge existing views, and offer a new perspective. And I simply can’t pretend things are okay when they are definitely not okay.

My training as a psychotherapist was traditional, in that I was taught to keep my personal views and opinions separate from my work with patients, and to not share anything about my personal life. When I was a young therapist, still in therapy myself to heal my own childhood wounds, that proscription suited me nicely. But over time, as I healed and matured, and as the field of psychotherapy itself changed, I began to share more of myself with patients. I brought my experience with therapy, 12-Step programs, and mindfulness meditation into sessions. I “showed up” for my patients in a new way, which not only felt more authentic for me, but also allowed the work we were doing together to go to a deeper level. This was more satisfying for me as a therapist, and led to deeper levels of insight and healing for my patients. 

I experienced a similar sense of satisfaction teaching mindfulness classes, as I was able to observe my students struggle with the practices week after week, and then suddenly have an “aha” moment that was transformational, perhaps life-changing. Even when I was teaching in the evening, after a long day of seeing patients, I would come home feeling grateful to be doing this work.

But the satisfaction, gratification, even joy that I experienced from my therapy sessions and mindfulness classes began to dissipate once everything moved online. I didn’t notice this right away, as I was so busy just mastering the technology, and relieved when it all worked and we could see and hear each other. And I was glad to be able to still provide support to my patients and students, as we all struggled through that initial phase of the pandemic.

Soon it became clear, however, that something was getting “lost in translation.” A day of Zoom sessions would leave me depleted, rather than nourished. Many of my colleagues noticed this, too (though I wasn’t seeing my colleagues in person anymore, either). Eye strain was part of it, as was the distraction of seeing myself as well as my patient on the screen. Phone sessions were easier in a way, and yet the challenge remained one of establishing a genuine connection. Telehealth can easily become simply a check-in. I noticed that mindfulness classes became more superficial, too. It’s difficult to dig deep into someone’s experience when you can’t see what’s happening in their body.

What I’m getting to here is what I’ve come to understand as a primary cause of my burnout: the loss of personal connection. Zoom and FaceTime are great tools that clearly have value as a way to connect, and I appreciate their convenience, but I think we’ve all come to realize that something gets lost, and that something is an intangible, hard to measure or define, energy. Without getting all “woo woo” I’ll just say, science has shown us humans are energetic beings, and we are biologically hardwired to read each other via “body language.” We also need each other’s physical presence for emotional regulation. We are “wired for touch.”

There’s another piece here for me, which is so personal that I’m hesitant to share it. During the past two years both of my adult sons moved to the East Coast, one of them taking my new grandson with. Talk about a loss of personal connection through touch! I wholeheartedly supported their moves as being right for them, and was able to appreciate what the Buddhists call “sympathetic joy,” when you’re happy for someone else’s happiness, even if it may cause you unhappiness. But still, it’s been a loss, one that I know many of you can relate to.

It’s not just my own lost connections that depleted me. As an empathic and highly sensitive person, I have felt a collective grief for the loss of millions of lives to COVID (a trauma that we have not fully acknowledged as a society). And I feel the effects of the many ways in which all of us have become isolated and disconnected from each other, both as a result of the pandemic as well as the polarized political climate. The positive energy I had once felt from the #MeToo movement and Black Lives Matter dissolved into despair, as women’s rights and BIPOC rights are increasingly threatened everywhere, ultimately at the level of the US Supreme Court.

There are objective data that confirm this societal trauma:  we’ve seen significantly higher rates of anxiety, depression, substance abuse and suicide, not to mention increases in domestic violence and gun violence, over the past couple of years. Besides political and economic factors, there’s a biological explanation for this too: when human beings lose their sense of connection with other humans, despair, hopelessness and alienation take over.

I didn’t arrive at this self-diagnosis until after I’d already embarked upon its cure. Sometimes we can only see clearly in hindsight; action is necessary before insight appears. As I began to see more patients in the office, led a few mindfulness meditation groups in-person in the park, and finally felt safe enough to travel to visit my sons and their families, my personal dark cloud began to lift. I also focused on “changing the things I can,” as the Serenity Prayer reminds us. This turned out to involve a move to a new home, with a dedicated and Zoom-friendly home office (after two and a half years of improvising) as well as a last-minute decision to find a way to keep my Pleasanton office, which I’d barely been using. Both decisions required navigating through uncertainty and letting go of control, but ultimately feel right.

Now I’m gearing back up to see patients two days a week in the office, following COVID protocols, while continuing to offer telehealth sessions the other weekdays, which feels like a more sustainable balance. I am also planning some in-person mindfulness classes for 2023, starting at Las Positas College in January-February. Today I’m meeting some new colleagues for lunch. And I am really looking forward to taking a week off next month for my first in-person meditation retreat in several years!

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Burnout in the Helping Professions

“There’s no shame in taking a step back to focus on self-care.” As I was saying this to one of my clients recently, it hit me: if I truly believe that, then I need to practice what I preach! It was obvious to me that my client was suffering from burnout, due to the demands of her job as a mental health professional as well as her family caregiver responsibilities, and equally obvious that she absolutely deserved to set some boundaries, ask for help, and take a break to recharge her batteries. And yet, even though I was beginning to see signs of burnout in myself, it was a real struggle to acknowledge this, and give myself the same permission to step back.

This is the dilemma that many of us in the helping professions face: if you’re a nurse, doctor, psychotherapist, social worker, or teacher, you may have received training to recognize the signs of burnout, and you may know what to tell your patients, clients, or colleagues to do to relieve it. In fact, you might spend your days counseling others to take a step back, set some boundaries, reach out for help, and get some rest. But when it comes to you, you’re far more likely to tell yourself to just push through the exhaustion, and ignore the growing cynicism and feeling of detachment from the work that you used to love.

So what exactly is burnout? The World Health Organization (WHO) defines burnout as “a syndrome resulting from chronic work-related stress, with symptoms characterized by feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.”[1] It is not a medical condition or mental disorder.

Christina Maslach, professor emerita of psychology at UC Berkeley and co-author of the Maslach Burnout Inventory (MBI), describes burnout as “feelings of exhaustion, inefficiency and cynicism, defined by a detachment from work and a lost sense of meaning.”[2] Developed in 1981, the MBI was the first instrument to measure burnout, and remains widely used today.

Are people in the helping professions more likely to experience burnout? According to recent surveys [3,4], burnout seems to be growing among workers across occupations, fueled by COVID-19 pandemic-related trends in working from home, remote schooling for children, and staffing shortages. But healthcare workers and educators have been hit the hardest, and even prior to the pandemic, these occupations have historically been most impacted by burnout. To understand why, we can examine the traits of people who are most vulnerable to burnout, but even more importantly, we need to look at the characteristics of jobs that burn people out.

Burnout doesn’t happen to slackers, but rather to those who are the most conscientious and hardest working, and who regard their work as a calling.[5] The traits of people who are most vulnerable to burnout include:

• Being a helper, by nature or occupation;
• Scoring high on conscientiousness and agreeableness (Big Five Personality test);
• Taking pride in one’s work ethic and dedication;
• When the going gets tough, they don’t quit, they just work harder; and
• They believe that asking for help is a sign of weakness.

Do any of those ring true for you?

Burnout is caused by chronic and excessive job-related stress, not by any deficiency in the individual. The characteristics of occupations that have highest rates of burnout include:

• Involving the provision of direct services to people in the areas of health, mental health, and primary education;
• Responsibilities are loosely or vaguely defined, additional responsibilities are constantly being added;
• Success is difficult to measure, there’s never an endpoint or goal post;
• Rewards are intangible, few, or fleeting;
• Job demands exceed what is humanly possible, given time and resource constraints.

Therefore, it is increasingly difficult to do the job well, or meet the needs of those you are supposed to serve. Does this sound like your job?

How do you know if you’re suffering from burnout? In my experience, these are the key signs:

• You’re more impatient or irritable than usual;
• You don’t feel well-rested after a night’s sleep;
• You’ve stopped doing activities that normally bring you pleasure or involve self-care;
• You find yourself saying or thinking more often, “I just don’t care” about your job; and
• You don’t feel ready to go back to work after your regular days off.

You may also find yourself getting more and more behind on routine work and household tasks, and thinking more often about quitting, changing jobs, or retirement.

A key point: burnout is not the same as depression. Because there is a significant overlap of symptoms, those who are suffering from burnout may believe, or may be told, that they’re clinically depressed, however, the causes of burnout are different, and so is the treatment. (Of course, it’s possible to have both burnout and clinical depression, in which case you will need to address both conditions.)

What is the treatment for burnout? Ideally, a signficant amount of time off work. For some people, a couple of weeks might be enough, for others, a month to a year may be needed. Of course, this is not possible or realistic for many people, so then you will need to implement these self-care tasks while continuing to work:

• Start with setting some boundaries. Learn to say “no,” or “not now,” and let go of any non-essential tasks;
• Ask for help from colleagues, or delegate if you can;
• Prioritize getting more sleep and exercise, eating healthier, and reaching out to family and friends for social connection;
• Change your attitude or approach to work. Become willing to be “good enough” rather than “great;” commit to leaving work on time, or if you work from home, create boundaries to separate work from home and family life;
• Take some time to review your life goals, and what gives you a sense of meaning and purpose. If it’s not your job anymore, then begin to explore other options.
• Finally, I highly recommend seeking out a psychotherapist to assist you in this process.

When I saw my client again, she seemed a bit happier, and reported that she had set some limits with the family members who had been most demanding of her time. She’d also resumed her exercise routine, was making plans for a trip with friends, and was actively looking for a job that was less direct-service oriented. And how did I address my own incipient burnout? I have decided to take a break from teaching mindfulness classes, even though I love doing so, to give myself more time for rest, relaxation, exercise, and visits with friends and family.

Notes:

1. Burnout an “occupational phenomenon”: International Classification of Diseases WHO. 28 May 2019. Referenced in Wikipedia page on occupational burnout.
2. Christina Maslach, quoted in Zuckerman, C (2021, April 30) How to Beat Burnout without Quitting Your Job. NYT online, retrieved March 28 2022.
3. Survey by Robert Half Int’l, referenced in Maurer, J. (2020, December 16) Remote Employees Are Working Longer Than Before. Retrieved from SHRM HR Today, online ed.
4. Threlkeld, K. (2021, March 11) Employee Burnout Report: Covid-19’s Impact and 3 Strategies to Curb It. Retrieved from Indeed.com.
5. From “The Exhaustion Funnel,” handout from my MBCT course.

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