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When the caring is too much

With the proliferation of research and information focusing on human-animal interactions, counselors are more aware of opportunities to incorporate animal-assisted interventions as part of their clients’ treatment. However, there is a population of clients who have been overlooked in this equation until recently — veterinarians. In fact, the mental health of these professionals is an emerging area of research and mental health treatment. We (the authors of this article) have also seen the pressures of this field firsthand with our family members and friends who are veterinarians and veterinary students. The sheer level of stress and strain they experience on a day-to-day basis has a significant impact on their work and personal lives.

For that reason, this article focuses not on animal-assisted interventions or the benefit of animals in their humans’ lives but rather on the increasing need of mental health attention to the helpers who take care of our pets and service animals. Note that although the information presented here may be applicable to others who work to care for animals, we are focusing specifically on veterinarians and veterinary students in this article.

We depend on veterinarians to be kind, compassionate and attentive to their patients and their patients’ owners. Because of the multifaceted nature of veterinary service, the occupational stress of these interactions and the inherent professional isolation of the field can result in a number of mental health challenges, including compassion fatigue, burnout, depression and anxiety. Veterinarians face some of the same challenges that other health care professionals face, including working with a large number of stressed clients (people and animals), long hours, and limited financial resources. However, they also have the added pressures of meeting the difficult requests and expectations of pet owners, making the best decisions given difficult situations, and dealing with unwanted or sick animals.

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In the Centers for Disease Control and Prevention report “Prevalence of Risk Factors for Suicide Among Veterinarians — United States, 2014,” Randall Nett and colleagues chronicled that veterinarians were found to experience serious psychological distress at a rate higher than the general U.S. adult population. Their survey of over 10,000 veterinarians in the United States further detailed that more than 1 in 6 veterinarians have experienced suicidal ideation. Belinda Platt and colleagues, in their study “Suicidal Behaviour and Psychosocial Problems in Veterinary Surgeons: A Systematic Review,” noted that these challenges have also contributed to the increasing rate of death by suicide among veterinarians. This information draws attention to the need for further consideration and development of support and assistance strategies for this community of helpers.

While neither of us has worked directly with this population, we do have a personal interest in this area. Christine has a close friend who is currently in her final year of veterinary medical training. The financial stress related to the cost of being in this professional program and uncertainty about how she will be able to pay off her college loans after graduation have caused her and her family significant worry. Even more startling are the stories about the strains the veterinary program puts on its students related to schedule, physical and mental demands, money, travel, etc. Christine’s friend has shared accounts of her peers breaking down in tears on a regular basis (sometimes several times a day), not sleeping or eating properly, pushing themselves to do more practice, and maintaining late night and early morning study times, sometimes alone and sometimes in groups, to prove themselves worthy to their faculty. The demands leave little (if any) time to engage in self-care, which seems to be affecting their current mental well-being and may be setting a precedent that will affect their mental health as they progress through their careers.

Fay’s daughter is a veterinarian who became interested in the high rate of suicide among veterinarians while she was in school for veterinary medicine. She explored the potential connection between compassion fatigue and suicidality and shared her work with Fay. After Fay’s daughter graduated and entered into veterinary work, she experienced the loss of colleagues to death by suicide. Our mutual concern about the high rate of death by suicide among veterinarians and the stigma felt by numerous veterinarians about seeking mental health counseling has prompted us to raise awareness of this issue with other counseling professionals. 

What veterinarians are saying about mental health

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Some of the mental health issues that veterinarians face are similar to those faced by the general population. However, international studies, particularly in Europe and Australia, report more significant mental health concerns within the veterinary profession when compared with the general population or with other health care professionals. The 2012 article “Suicidality in the Veterinary Profession: Interview Study of Veterinarians With a History of Suicidal Ideation or Behavior,” by Platt and colleagues, indicates that specific challenges of workplace relationships, career concerns, patient issues, unreasonable work hours/work volume, and responsibilities related to clinical practice management are all contributing factors to veterinarians’ mental health issues. Research also notes that student debt and ethical dilemmas, most notably around issues of animal care and euthanasia, generate the highest levels of stress for this population. In a 2018 article for JAVMAnews (Journal of the American Veterinary Medical Association), R. Scott Nolen noted that veterinarians show a higher rate of psychological distress and have slightly lower degrees of well-being than does the general population. The seriousness of this dilemma is more significant when considering that 25% of veterinarians have considered suicide at some point in their lives and 1.6% have attempted suicide.

In their review of the practice of veterinary social work, Elizabeth Strand and colleagues found evidence suggesting that veterinarians may experience stress, anxiety and depression as early as their first year of study. High-achieving students are often drawn to veterinary medicine, and among this group, failure is not an option. Veterinary school is demanding and requires a great deal of time and energy from students, beginning with the acceptance process and continuing through clinical practical experiences. Rates of depression, self-harm, and suicidal ideation increase during the clinical year when students are completing medical rotations in various specialties of veterinary medicine. The rigor of each rotation and the requirement of completing multiple rotations, which can be located either near or far from home, present other challenges for managing stress and the life skills of students. Although the social support offered by family, friends, and veterinary faculty was found to be beneficial to these students, we believe the specialized training of mental health practitioners might improve outcomes for veterinary students during their course of study.

The debt acquired through the course of study can become a significant contributing factor to the stress levels experienced by veterinarians at the beginning of their careers. A review of the 2019 cost of veterinary medicine programs throughout the United States indicates that a four-year residential program can range from $168,000 to $329,000, whereas a nonresidential program can cost between $223,000 and $460,000. The median debt carried by veterinary school graduates ranges from $96,000 to $329,000. Given the significant cost of a four-year veterinary degree, it is easy to identify another reason for increased stress, anxiety and depression among this population.

The function of a veterinarian is not only to provide top-quality medical care to animals and to maintain a relationship with pet owners but also to do so in a compassionate manner, even when it creates significant stress for the veterinarian. Many veterinary professionals become overwhelmed when they need to offer emotional support and comfort to patients’ owners because they are not adequately equipped to handle the owners’ emotional responses. This is especially true when having to convey messages about a patient’s illness or death.

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In her article “Moral Stress the Top Trigger in Veterinarians’ Compassion Fatigue,” Susan Kahler noted that giving bad news, managing adverse events, interacting with difficult clients, working in teams, and balancing work and home life create diminished levels of wellness for veterinarians. This work cannot be done in isolation, and the support staff in a veterinary hospital is a key component to the relationship between veterinarian, pet and pet owner. People trust that veterinarians will interact sympathetically with them, but managing these multiple relationships, in addition to providing ethical and professional care and respecting the dignity of the patient and patient’s owner, can be a challenge. This is especially relevant when considering that veterinarians encounter difficult issues — including cases of trauma, illness, abuse, terminal illness and death — on a regular, sometimes daily, basis.

Another identified contributing factor to the mental health issues of veterinarians is the ongoing pressure inherent in the daily operation of a clinical practice. In addition to the stress of managing the business side of the clinical practice (billing, inventory, equipment, payroll, legal, etc.), veterinarians are now dealing more frequently with “emotional blackmail,” which involves attempts to guilt these professionals for charging for their services. Just as we have seen in other industries, consumers of veterinary services are increasingly turning to social media to complain about products and service. In “Media’s Emotional Blackmail Is Killing Veterinarians,” Dr. Sarah Boston, a veterinary surgical oncologist, explained, “There are several results of this irresponsible reporting. The obvious one is the direct damage to the veterinary hospital and staff. There is also the widespread damage it does to all veterinary professionals when they receive the message that what we do is not valuable and should not cost money, and that we are terrible people who are only in it for the money.”

Suggestions for all helpers

Until recently, wellness and mental health self-care were not included in the curricula of veterinary training programs. Because veterinarians tend to be empathetic and nurturing, they focus their efforts on caring for and promoting the health and well-being of animals and routinely put the needs of patients and patients’ owners above their own. In her article on moral stress, Kahler explained that moral stress is unique in that the typical stress management techniques are useless and may even contribute further to mental health challenges. She encourages these professionals to redefine their work ethic to include self-care.

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Self-care is really a moral imperative for all professionals in the helping fields, including veterinarians. Helping professionals have a moral obligation not just to facilitate patient care but also to take care of themselves. In collaboration with university training programs, mental health care professionals and counselor educators can help start this process by integrating self-care, stress management skills, and education about mental health issues and substance abuse into veterinary school courses. The College of Veterinary Medicine and the College of Social Work at the University of Tennessee created a collaborative partnership in which focus is given to animal-human interactions, including the issues of compassion fatigue and conflict management.

University counseling centers can also be invited to have greater presence during professional development seminars with veterinary students. This can help erode the stigma of students and professionals seeking mental health care when it is needed. The colleges of veterinary medicine at both Ohio State University and Colorado State University have taken proactive positions in providing resources and education to their students about mental health and self-care.

In addition to reaching out to veterinary programs to capture the attention of students, professional counselors might consider reaching out directly to veterinary professionals. The integration of tools to manage school-work-life balance should be incorporated at both the student and professional levels.

Moral stress and its associated challenges — compassion fatigue, burnout, depression and anxiety — can feel insurmountable to manage. Veterinarians are generally problem-solvers, analytical thinkers and high achievers. They tend to be task oriented and strive toward order. These characteristics certainly help veterinarians to be good at their jobs, but they do little to help these professionals remain good “in” their jobs. Although veterinarians are empathetic toward their patients, some may lean toward low self-awareness and struggle with understanding or dealing with their own emotions. Incorporating opportunities to promote emotional intelligence during veterinary programs and professional development trainings can help these professionals to become more aware of their emotions and the emotions of others, which in turn facilitates better management of themselves and their relationships with colleagues, staff members and patients’ owners.

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Mental health professionals can assist veterinarians with increasing awareness of their emotional reactivity and help them take a more proactive approach to self-understanding and emotion regulation. Daniel Goleman popularized the psychological theory of emotional intelligence and its five components: self-awareness, self-regulation, internal motivation, empathy, and social skills. These components can easily be assimilated into training and wellness interventions. Emotional intelligence enhances the individual’s ability to reroute their thinking, allowing them to move away from their initial emotional response to situations (including avoidance) and toward more action-based reasoning.

Many times, veterinarians with a history of suicidal thoughts or behaviors do not talk about or share their experiences with anyone because they feel guilty or ashamed. Their silence may also be attributed to a fear that reaching out will affect their job, or simply to a feeling that they do not have time to seek help. Providing a space for group work, whether in person or virtually,  allows veterinarians to develop support networks. Kahler explains that group time presents veterinarians with a setting to talk about and debrief their experiences and memories together in an open, safe forum. When this group interaction occurs, the group members start making sense of their situations and learn that they are not isolated in their experiences.

One of the major stress factors for this group of professionals is their reported lack of time. Especially for those with busy schedules or those who work in rural areas, telemental health services may be a particularly attractive option.

In addition, bibliotherapy is a brief adjunct intervention that is helpful with a variety of psychological problems. It can be a resource for veterinary professionals with busy schedules or for those who work in locations far from traditional mental health offices. Bibliotherapy is used to increase clients’ understanding about what they are experiencing, and it promotes agency in their treatment. In their systematic review of the use of bibliotherapy in the treatment of depression, Maria Rosaria Gualano and colleagues explain that there is a self-help element to bibliotherapy. It teaches, through the reading of specific material, a number of strategies designed to regulate negative emotions and explains how to practice them in daily life. Bibliotherapy interventions are best used in conjunction with counseling. They can be used between counseling sessions to enhance clients’ commitment to working toward health and well-being.

Finally, mental health professionals can help by providing education, maintaining open opportunities for collaboration, and advocating with the veterinary field to promote well-being and reduce stigma around mental health issues and counseling.

Conclusions

The suicide rate among veterinary professionals is higher than that of other professional fields due to the unique responsibilities of veterinarians. Veterinarians, like other helping professionals, are at risk of giving too much of themselves to their patients and their patients’ families, their staffs, and their businesses and leaving little time for themselves because of their natural qualities of compassion, empathy and caring. A variety of stressors, starting during veterinarians’ programs of study, can lead to mental health issues over time.

On the basis of what we have learned, we believe that providing access to counselors and other mental health professionals could help veterinary students become more proactive in managing some of the emotional challenges they may face as they move through their programs of study. In addition, counselors working with veterinarians in the community can help these clients identify any unhealthy coping methods and provide opportunities for promoting resiliency and wellness. This may require offering strategies that extend beyond the counseling office because of the veterinary profession’s time demands.

Resources

Various resources are available to counselors working with these gifted healers and for veterinarians themselves.

The American Veterinary Medical Association (AVMA) lists several articles and resources for its members and for those who work as veterinarians. Among the areas highlighted under AVMA’s professional development dropdown menu at avma.org are well-being and peer assistance.

The University of Tennessee veterinary social work program provides referrals and resources to people in veterinary practice. The university’s S.A.V.E (Suicide Awareness in Veterinary Education) mental health education program, which was created to honor a colleague’s last wishes, has served as a model for mental health education in veterinary schools across the country (see vetsocialwork.utk.edu and vetmed.tennessee.edu/SAVE).

The National Suicide Hotline (suicidepreventionlifeline.org) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, seven days a week.

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Christine Sacco-Bene is a licensed professional counselor and licensed mental health professional. She is an associate clinical professor in the Rehabilitation Counseling Department at the University of South Carolina. Over her 15 years as an educator, she has been an advocate for students and professionals in the field of counseling (and in all helping professions) to engage in self-care activities to support their mental well-being and professional growth. Contact her at christine.sacco-bene@uscmed.sc.edu.

Fay Roseman is an associate professor in the counseling program in the Adrian Dominican School of Education at Barry University in Florida, where she also served as the coordinator for practicum and internship. As a practitioner certified in the Myers-Briggs Type Indicator, she teaches career development and other courses in the master’s and doctoral programs. Contact her at froseman@barry.edu

Letters to the editor:  ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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