Doctors and the difficulty of admitting to issues of mental health

Evelyn Lewin

7/09/2020 2:51:41 PM

Doctors can find it hard to ‘practice what we preach’, according to consultant psychiatrist Dr Eli Kotler.

Stressed GP
With many ‘everyday’ ways to deal with emotional issues limited or unavailable during the pandemic, it is understandable that stress and anxiety levels are rising.

‘It’s hard for the general population to admit that they have vulnerabilities, flaws and weaknesses, and I think that can potentially be even more difficult for doctors.’
That is consultant psychiatrist Dr Eli Kotler, medical director of Malvern Private Hospital and an adjunct lecturer at Monash University School of Medicine, speaking to newsGP about the difficulties doctors face in seeking help for mental health issues.
Dr Kotler says doctors’ personalities often tend towards perfectionism and may therefore struggle to admit to having such issues.
‘Also, maybe they are used to being seen as someone who maybe doesn’t have problems like other people have problems, and they’re someone who’s looked up to,’ he said.
‘So it can be difficult to admit to ourselves and other people that we have issues, because that’s admitting a vulnerability and many of us don’t like to do that.’
And yet, Dr Kotler is concerned that doctors’ mental health may worsen during the pandemic, especially in Victoria, which will remain  under stage four coronavirus restrictions until at least 28 September.
Most people have ‘everyday’ ways to deal with emotional issues, such as going to the gym, socialising and simply having time to themselves.
With these outlets currently not available or limited, however, Dr Kotler believes it is understandable that stress and anxiety levels are rising for everybody, including doctors.
Then there are the additional pressures faced by clinicians working in the current climate.
‘There are so many changes and trying to keep up with those changes can be challenging,’ he said.
Dr Kotler says GPs must ask themselves additional questions during the pandemic.
‘When to see people? Who I can see? Is it safe to see this person? Do I have to isolate? Do I not have to isolate? What are the latest guidelines? Do I have to send this person to hospital? Will hospital even accept them, or will they send them away?’ he said.
Adding technology into the mix can increase stress, as can the isolation faced by doctors who are working from home.
Dr Kotler says the pandemic has been an increase in loneliness, disconnection, social isolation and sadness, all of which can ‘play directly’ into people’s pre-existing mental illness or lead to development of other mental health issues.
GPs working with suspected COVID-19 cases may also be fearful for their own health.

‘It can be difficult [for doctors] to admit to ourselves and other people that we have issues, because that’s admitting a vulnerability and many of us don’t like to do that,’ consultant psychiatrist Dr Eli Kotler said.

In May, newsGP reported on research that tracked the impact of viral epidemic outbreaks on the mental health of healthcare workers. While not peer-reviewed, the research concluded that the prevalence of anxiety, depression, acute and post-traumatic stress disorder, and burnout is both during and after the event.
As the stress of the pandemic continues to take its toll, Dr Kotler says there are ways GPs can help care for their mental health during this time.
A good place to start is practising mindfulness and checking in with one’s emotions, thoughts and behavioural patterns.
‘[We need to] practice what we preach,’ Dr Kotler said.
‘It’s actually very difficult to practice what we preach, particularly in regards to mental health, and that’s because no one actually wants to face their emotional issues.’
Dr Kotler has found it is more common for people to choose to escape from such issues.
‘We tend to want to run away from ourselves and distract ourselves and not really focus on what we’re doing and what we’re thinking and what we’re feeling,’ he said.
‘But I think that can be a really healthy experience for GPs to actually try and practice it.’
Dr Kotler says this is also a useful exercise to help understand the barriers patients have when advised to practise mindfulness.
‘Because it’s one thing to tell people to do things, but I think it’s really useful to understand the resistance that people have in doing these things,’ he said.
‘Mindfulness exercises … are actually extremely difficult because our bodies fight against it, we don’t want to sit with ourselves and breathe and meditate and be with our emotions – we run away from it.’
While it is common for people to seek to escape their feelings, Dr Kotler says people who do that ending up ‘getting very unwell from a mental health perspective’.
‘It’s people that can sit and work through their emotional difficulties that don’t get so unwell,’ he said.
Dr Kotler explains that mindfulness involves exploring thought patterns, such as whether there is negative thinking or self-critical thoughts, feelings like loneliness or sadness, or behavioural patterns.
He says a lot of behaviours in which people engage are unconscious ‘compulsive coping strategies’ they perform due to underlying emotional reasons.
‘It’s really good to check in on myself [and ask], what am I doing? Am I perhaps doing things to escape my emotions?’ he said.
‘Am I starting to compulsively exercise or drink too much beer or smoke too many cigarettes? Am I arguing a lot with my wife or my kids?
‘Am I getting really angry at people or getting really angry with myself and getting self-critical?
‘All these compulsive tendencies that we can unknowingly be repeating and carrying out in our lives [are there] just to ward off different emotional states.’
While thinking about ways in which your behaviours may be deflecting from underlying issues, Dr Kotler says it is also worth exploring professional attitudes to patients.
‘That’s also an important thing to do to monitor myself with my patients,’ he said.
‘Hhow do I feel with my patients? Am I feeling really frustrated? Am I still happy to see people? Are people making me very anxious or annoyed?’
After spending time checking in with those parameters, if an unhealthy emotional, thought or behavioural pattern is identified, the next step is to ‘actually do something about it’, according to Dr Kotler.
But that in itself is a significant challenge.
‘We can have a whole lot of different blocks and defences up against actually dealing with our problems because we can develop this sense that, “I can’t have a problem”,’ he said.
Dr Kotler says the first step in seeking help is ‘admitting to ourselves’ that there is an issue.
The next step is speaking to someone about it, whether a good friend, spouse or another trusted person.
Seeking professional help is also an option, Dr Kotler says, speaking to your own GP or a psychologist, or through state-based organisations such as the Victorian Doctors Health Program, that provide free, confidential help for doctors with mental health concerns. 
‘This is a very stressful time for many of us,’ he said.
‘There is a very real risk that doctors will become overwhelmed, and all of us will suffer from emotional turmoil to some extent.’
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Dr Christopher Michael Bollen   11/09/2020 9:27:06 AM

And those people who own practices do need to look at the practice culture which they have influenced through their active or passive leadership. Owners of genera practices could take time to reflect and listen to their teams including the other practice partners and contracted GPs, to find out whether the culture is "command and control" or "care and connect". The place we go to work has a huge impact on our mental health as GPs. Do we have practice buddies? Are lunch breaks encouraged and peer discussions supported? Does the practice have an employee assistance program (EAP)? Does it promote the RACGP EAP for GPs which allows access to anonymous counselling/support? There are many other ways of creating supportive practice cultures. Just getting enough sleep, exercising and eating right is not enough to really make the impact on a GPs mental health.