Burning Out: Resisting Resilience and Self-Care Narratives
Guest Post
by
Suze Berkhout, M.D., Ph.D.*
As a psychiatry resident, the recent CBC and Toronto Star headlines proclaiming high rates of burnout, depression, and suicidal ideation in the Canadian medical profession came as no surprise to me. Even less surprising was the finding that these numbers were vastly higher amongst medical residents in Canada. Increasing demands and expectations, overloaded schedules, decreasing ability to make effective changes within the Canadian medical system, and conflicting values—humanistic approaches versus cost containment, for instance—are rampant. In addition, larger workplace cultures frequently value competitiveness, perfectionism, and certainty over admission and acknowledgement of flaws, limitations, and doubt. For residents and medical students, add in debt, a pervasive hierarchy, and even less control, and you’ve got a perfect storm.
Burnout—the combination of physical and emotional exhaustion, feelings of ineffectiveness or lack of accomplishment, and experiences of cynicism and detachment—are surely a logical conclusion to these structures and environments, not a personal tragedy.
This critical state of affairs is not just an issue for physicians, or even health professions more generally. Academia is rife with these same structures and their consequences. Not surprisingly, burnout is increasingly an issue discussed in higher education. And the impacts of structural inequities on women academics, academics who are members of racialized and other minority groups, and disabled academics are profound. We are the ones least likely to be on a tenure track and more frequently in precarious forms of employment; we are the ones most often tasked with unrecognized and unremunerated emotional labour; we are more likely to face biases in the practices of peer review, impacting publication opportunities, grant acquisition, and promotions. Yet our assertions around issues of equity and justice are more likely to be met with scepticism at best, hostility and retribution at worst.
The testimonial and hermeneutical injustices faced by individuals “othered” along various intersectional identities must also be understood as part of the burnout picture. Testimonial injustice occurs when a speaker is deemed to lack credibility due to prejudicial beliefs by the listener—typically these beliefs relate to some aspect of the speaker’s cognition, formed in a way that is resistant to counter-evidence; moreover, these prejudicial beliefs reference sociohistorically extended patterns of oppression beyond a given interaction (Wanderer 2017). Hermeneutical injustice is the systematic constraining or undermining of communicators’ intelligibility which leads certain groups to be at a disadvantage with respect to making sense of their social experience. Injustices of these types radically curtail one’s voice, one’s interpretive capacities, and one’s ability to participate in meaning-making (Medina 2017). The wrongs relating to these forms of injustice are numerous, not the least of which is the way in which they maintain asymmetric and problematic relations of power.
The exhaustion, ineffectiveness, and detachment that signify burnout are surely linked, at least for members of certain groups, to the processes of epistemic subordination and exclusion, as well as a diminished ability to make sense of the position in which one finds oneself. Yet, if one were to look at the popular literature around the subject of burnout (here and here, for instance), it would seem that a combination of time management, gratitude journals, and yoga are all that it takes to combat the pervasive sense of helplessness and ineffectiveness that comes with the burnout territory. Emphasis in the literature has also been placed on how individuals make choices related to their professional life, including whether these choices align with their skills, temperament, and values. Even if these recommendations and other information are (to some degree) helpful, they individualize and privatize what is clearly an issue with deep structural and historical roots. They do nothing to contend with either structural inequalities or the forms of epistemic injustice described above.
Will improving your vinyasa fundamentally shift the relations of power that limit the agency of certain groups, systemically suppress their epistemic standpoint, and discount their assertions? I like endorphins as much as the next person, but surely scheduling in more self-care isn’t the answer. Or, it is an answer, but one that leaves unchallenged larger forces that underpin burnout. Individualizing and privatizing solutions to burnout displaces the responsibility for its “cure” onto the very people who have limited access to the mechanisms and privileges that enable systemic change, while absolving the very people who benefit from current structures of accountability.
Happily, I’m not the first person to notice this. In a recent Doximity blog post, Dr. Pooja Lakshmin also raises ire with the resilience refrain that has become so popular in medical culture, pointedly articulating that resilience and (what she rightly terms) “faux self-care” puts the burden of change on the individual while exonerating the system. I only worry that Dr. Lakshmin’s discussion of setting work-related boundaries—knowing your own limits, tolerating others’ disappointment that you are not placing their needs first, and not internalizing these as moral failings—is a strategy primarily available to people whose labour is both well-remunerated and falls outside the scope of precarity. One needs to have attained a certain level of social capital in one’s work to be able to avoid the negative repercussions that often accompany not being seen as a “team” player. Sessional and contract workers in academia, as well as early-career individuals (particularly women and members of racialized groups) don’t often have the luxury of turning down tasks that are presented to them as “opportunities,” either because of financial need or because of the optics and biases that come with pushing back.
In my previous guest post on Disadvantage and Discrimination, I discussed the ways in which mental distress has been divorced from structural injustice, in part through a technological paradigm in psychiatry. This paradigm gains greater traction within the neoliberal political rationality that suffuses contemporary social institutions and ideologies. Framing responses and resilience to burnout in terms of making “better” choices and taking part in self-care (whether going to that hot yoga class or ensuring that components of your job description match your temperament) is neoliberalism par excellence. Self-care becomes nothing more than self-responsibility and self-reliance, undermining the collective and relational ontology of burnout and its fixes. Even boundary setting, at least on its own, can also be more of the same responsibilizing.
That’s not to say that setting limits around what you will and will not do is unimportant; when carried out within a larger collective, it does have the potential for systemic change. But boundary setting, like “faux self-care” and professional or work-related choices, can end up as a kind of Foucauldian “technology of the self”: those practices, operations, and means of conducting one’s body, soul, thoughts, and ways of being so as to pursue and attain a state of happiness, purity, wisdom, etc. (Foucault 1988). Thinking about these issues in terms of technologies of the self enables us to understand how the sorts of burnout strategies discussed above can be conceptualized as the workings of a neoliberal governmentality and its relation to late capitalism, and how a different, collective, approach might be needed instead.
Do I have the answer to solving the burnout problem in medicine or academia? Not really. But surely the answer isn’t something like scheduling in a hike or a spa day. These activities are merely pleasant distractions from the bigger picture, distractions that may not even be affordable to people in precarious employment situations. Shifting dynamics and relations of power within the workplace would be some sort of solution; however, doing so requires coordinated and collective action and larger movements that emphasize social change. Reconfiguring workplace power relations would also require the development of novel ways of holding the institutions in which we’re embedded accountable. How to do that without demanding ever more of the people who already struggle with the burdens of burnout is an open question and a pressing one at that.
References
Foucault, Michel. 1988. Technologies of the Self. Amherst: University of Massachusetts Press.
Medina, José. 2017. Varieties of Hermeneutical Injustice. In The Routledge Handbook of Epistemic Injustice, eds. Ian James Kidd, José Medina, and Gaile Pohlhaus Jr. London: Routledge.
Wanderer, Jeremy. 2017. Varieties of Testimonial Injustice. In The Routledge Handbook of Epistemic Injustice, eds. Ian James Kidd, José Medina, and Gaile Pohlhaus Jr. London: Routledge.
*Suze Berkhout, M.D., Ph.D. is a psychiatry resident and clinician investigator at the University of Toronto. She completed her Ph.D. (Experimental Medicine, with a concentration in feminist philosophy) at U.B.C. Suze Berkhout’s research interests sit within medical humanities and feminist philosophy of science.
posted by Shelley
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