Data on mental health amongst US doctors, even pre-COVID was very concerning. Research suggests that in 2020 there were rising levels of depression, burnout, and suicide amongst US doctors[1].
Subsequent studies during the COVID pandemic also suggest high levels of depression, anxiety, burnout, and insomnia amongst health care workers, not only in the US but around the world. A study in Spain of over 2,000 health care workers in 2021 found that 38.58% of participants had clinical depression and over half had clinical levels of anxiety, higher than in other studies of the wider adult population[2].
The results in Spain were largely explicable by the devastating impact that COVID-19 had on the healthcare system. Those working directly with COVID-19 patients suffered significantly greater mental health problems that other healthcare workers. Similar studies found differing outcomes in different countries. The mental health of healthcare workers was indirectly influenced by the effectiveness of the government response, the level of pandemic preparedness, and agility across the healthcare system to respond to the pandemic in a way that supported the frontline.
Systemic factors are of critical importance in workplace wellbeing. The availability of online mindfulness apps, resilience training programmes, or workplace counselling services can help to a degree. But how work is designed, the availability of adequate and appropriate resources for the work, and how well people are led, supported and equipped in complex situations also matter.
There may be times in many professions when we expect to be on something equivalent to a ‘war footing’. But some people I meet show signs that they are on a near permanent war footing. They are in a permanent state of crisis as they lurch from one serious problem to another. I regularly work with people who have goals they set for themselves, or which are set by their organizations, which are ambitious to the point of absurdity, rather than healthily stretching and sustainable. As such, their minds are in a permanent state of high alert. There are few, if any periods of relative calm.
Cognitive, emotional, and behavioural agility, are arguably a pre-requisite for admissibility and success in many professions and organizations. I see that agility (in which resilience is a factor), is sometimes couched in different language such as 'comfort with ambiguity' or 'ability to manage change'. It is a selection requirement one way or another for most managerial or leadership roles.
In some roles there is also a tacit expectation of self-sacrifice at times, in service of a certain mandate or overarching mission. Some top-tier corporate law, investment banking and management consulting firms, armed forces, and emergency services, are candidates for sectors that have an implicit or explicit expectation that people will have very high ability to function well for extended periods in extremely uncertain and stressful situations.
However, research on mental health around the world, across many different sectors and professions is revealing increasing levels of unhealthy stress and burnout, despite the availability of enabling technologies to simplify and streamline work. For millions of people, working life feels more stressful than it should, often for inadequate rewards within extremely unequal societies.
In the UK, this has resulted in increasing numbers of highly qualified people exiting the healthcare sector, for examples, and a serious staffing crisis, exacerbated also by HR and public policy failures. The hospitality, logistics and transport sectors are experiencing similar problems with recruitment and people management. Engagement and wellbeing are hot topics, with many dimensions and psychological complexities.
In this challenging context, a difficult judgement I face when working with professionals in a coaching, leadership development, or organization development capacity, is how much their self-reported level of work-related stress is driven by external factors, aspects of the larger systems that they work within, and how much may be a consequence of patterns in their own thought and behaviour.
Sometimes there is just a mismatch between the abilities or preferences of the people doing certain work and the demands of the work. This in turn may prompt questions about career choice. I regularly also encounter professional people who put unhealthy pressure on themselves to perform at levels which are unsustainable in pursuit of goals which may be unrealistic. The antecedents to this tendency are usually difficult to unpack.
Then again, real caution is needed here, as it is not my place to advise people on the realism or otherwise of their aspirations, or to try to change their level of ambition unless it seems seriously irrational, harmful or delusional in their own context. Humanity's greatest achievements emerge from a lack of realism. Coaching psychology needs to help people define and achieve their goals, which at times constitute a long-held personal dream, a desire to achieve elite performance in a field, or a deep desire to help or serve others in some way.
A sense of responsibility, or duty to others, if it is taken too far, or exercised in a way that is subtly controlling, can be counter-productive, for ourselves and the people we think we serve. This is not just because of the dysfunctional dependencies it can create, but also because of the unnecessary self-sacrifice it may require. My challenge is, at times, to help people fulfil their purpose and potential, without in some way and for whatever deeper reasons, punishing themselves.
To illustrate how I might support someone dealing with early symptoms of burnout, I will share a brief scenario. This is entirely indicative, and draws on experiences I have had, especially of working with people who have a mix of exacting personal standards, a deep sense of service to others, and very high conscientiousness.
In this scenario I am coaching a fictional doctor called Sara, who is works in an accident and emergency department. In an early conversation with Sara, she says the following:
‘I will always go above and beyond for my patients, always. I work through breaks. I stay late to complete paperwork and make sure lab tests are done. I must not and I cannot afford to say no, or to make a single mistake. Patients come first. Lives are at stake. Patients’ families expect us to take care of their loved ones, right?’.
Sara is demonstrating her deep commitment to her patients and her team. However, working through breaks consistently, staying late, feeling that she ‘cannot afford to say no or to make a single mistake’, start to ring alarm bells in my own mind about whether she has unhealthily and unsustainable perfectionistic tendencies.
If statements like this are repeated often, these might be signals of her own psychological vulnerability, possibly to a system that is exploitative of her goodwill, and perhaps of proneness to unrealistic thinking and insufficient attention to self-care[3]. But I would remain very cautious about making too many inferences too quickly. It would be especially unfair and unhelpful to assume that Sara’s pressures are completely down to her own choices, or for her to feel personally judged on that basis.
As our dialogue proceeds I start to explore some things that Sara can do to reframe her role, and to respond to her situation differently.
Drawing on coaching psychology and on counselling research in clinical settings[4][5], I would seek to acknowledge Sara’s unsustainable workload and pressure, while carefully also drawing her towards a solutions-focus.
The advantage of a solutions-focus in this context is that it is an action-oriented approach which can be deployed in relatively short timeframes, even in just one or two conversations. It does not necessarily require Sara to invest in a long series of very analytical or deeply exploratory sessions over several weeks or months. In Sara’s current situation, to insist on a more drawn-out process might not be helpful or practical. It might even add to her stress.
Remaining sensitive to the immediate realities of Sara’s situation, and her constraints, I respond to her by saying,
‘I am moved and inspired by what you are doing. Your commitment to patients is very clear and comes across very strongly. For how long do you think you can sustain this level of commitment?’
‘Deep down I know I can’t carry on like this.’ Sara replies. ‘I am completely exhausted physically, mentally, and emotionally. I don’t feel I’m at all in control of my workload or my life. But I can’t just switch off. All I do is work. I just keep reminding myself of what they’re going through – the patients. The whole thing is just…a bit of a nightmare. My relationships have suffered.’
‘It sounds like you are finding some aspects of the work – especially your workload - overwhelming right now, and that’s completely understandable given the circumstances’, I respond.
Sara nods and seems to notice that I am being patient, empathic and non-judgmental in acknowledging her situation.
‘Let’s start by taking a step back, OK?’.
‘OK’, Sara replies, her tone, facial expression, and posture suggesting anxiety mixed with curiosity, and some incredulity.
‘Try to think about a time when you have felt you are performing well, and at the same time feeling more in control of your time. This might be difficult, so you can also just tell me about what this sense of balance would look and feel like to you on a good day. Take your time.’
In this interaction, as a psychological coach, I choose not to focus Sara’s mind on describing in detail, analyzing, or digging into her problems to identify all the possible root causes and past experiences. A different, more analytical approach might be warranted with other clients, who have the capacity to go deeper into their own histories and learned patterns of belief. But with Sara, at this stage, I make a choice to focus more on her lived experiences and her current options, not on problems. My intention is not to downplay how or why she arrived at this point, but given the time pressure, to focus her mind on possibilities and constructive actions.
A coaching psychology professor, Anthony Grant, put forward a simple two-by-two performance and wellbeing matrix[6] , which is a helpful tool in these situations. This matrix has performance and wellbeing on two axes, which then divides individuals into four quadrants.
Distressed but functional: (high performance – low wellbeing)
Distressed and Dysfunctional (low performance – low wellbeing)
Happy Nonworker (low performance – high wellbeing)
Flourishing (high performance – high wellbeing)
Grant proposes that ‘flourishing’ is an aspirational zone. Existence within the matrix is dynamic for individuals. The task for coaches is to recognize what quadrants their clients are in, and to facilitate movement away from low wellbeing. It seems to me that Sara is showing up as 'distressed but functional'.
After exploring with Sara what feeling more balanced, and in control of her work and life might look like for her, I explore with Sara how she might give her best without feeling permanently exhausted. Following Grant’s research on taking a solution-focused approach to stress reduction, my approach is:
(a) help Sara to identify where she is now in terms of performance and wellbeing (using the matrix mentioned earlier as a visual aid perhaps), and where she thinks she could be; we would then discuss how to improve her wellbeing and reduce her workload
(b) encourage Sara to articulate specific goals and related activities that would support stress reduction
(c) invite Sara to identify resources and options and formulate action plans; this would also require her engagement with the right stakeholders in her organization, and I would spend some time helping her think through how to approach and manage those stakeholders so that her workload might be managed better
(d) ask her to identify personal strengths that she can harness without setting impossible performance expectations on herself – and so build her self-efficacy and motivation
(e) suggest that she regularly evaluates her progress towards feeling adequately energized both during and after a crisis situation in her department and
(f) takes continuous action without creating yet another source of pressure for herself (so focused on her pursuit of greater self-care that this becomes another sources of stress).
With a client in Sara’s situation, it helps to encourage better self-monitoring, with compassion, offering practical feedback on her ideas for altering both her situation, and her response.
Clearly, there is much that lies outside of our personal control where performance pressures and workload are concerned, in many professions and organizations. This is indeed a perennial issue which comes up again and again in my work with managers and leaders as well as frontline professionals. This is especially true in a world in which many performance consultants and popular executive coaches (I won't name any names) like to focus boards' and senior leaders' minds almost entirely on how to drive higher performance from the people who do the work, without paying any serious attention to their wellbeing.
There are interventions required at the ‘whole-system’ level to alleviate unhealthy pressures on people caused by excessive workload, inadequate tools and resources, poor prioritization, and bureaucracy. This is where some of my organization development consultancy work is targeted, at a whole-system level.
However, there are also thought processes and coaching tools that can help individuals feel more in control and manage their own response to unsustainable workload, or other sources of unhealthy work-related stress. If a person like Sara needed additional or alternative referral for counselling or psychological support of a clinical nature, a coach with appropriate boundaries would discuss and agree that with Sara, to ensure she receives the right help at the right time from qualified clinical professionals[7] .
It is vital that we acknowledge the need for systemic solutions to workload problems and pursue systemic approaches. At the same time, coaching psychology practices can help people build their sense of agency and seek the support that they need to function at their best – through both a performance and wellbeing lens. Indeed, pragmatic solution-focused coaching practices which are engrained within a workplace culture, such as Sara’s, can support systemic approaches to address chronic overwork, stress, and burnout.
Many of our problems at work are caused by a cultural inability to share problems with each other without fear of being judged. Healthy organizational cultures encourage people to find ways forward together. Teaching more people at all levels of an organization how to coach each other in the tumult of work, even during a crisis, using quick, practical, simple coaching tools, is one way to improve performance and mental health at work. Giving people personal access to a virtual coaching service on an app may be helpful, but it is the internal culture and experience of everyday human encounters at work that really count.
In this way, a coaching culture demonstrates care, while enabling a sustainable, agile response to uncertainty. The opposite of a coaching culture is one that sacrifices the health or the careers of good people for the sake of business expectations or performance goals which are conceived and implemented entirely 'top-down'.
There are performance coaches who are obsessed with extreme or elite performance, often name-dropping the celebrity athletes, gifted artists, Nobel prize-winning scientists, famous explorers, global leaders and billionaire entrepreneurs they have 'interviewed' (often more superficially than they admit), or claim to have worked with. This has little bearing on the mundane and sometimes grueling realities of many jobs and careers. People can find the presence of some consultants and coaches in their organizations alienating, even a source of shame as they struggle to live up to the standards being set.
To empower people at work we have to help them find ways to achieve meaningful and realistic performance goals, while also designing the work in a way that enables wellbeing. It is also worth investing in developing cultures in which coaching conversations are a normal part of how people communicate with each other, regardless of their 'reporting' relationships. That requires business owners, leaders and HR teams to invest in collective human development.
[1] Estroff Marano, H. (2020). The Healers Are Hurting: For Many of the Nation’s Physicians, Doctoring Has Become an Almost Unrecognizable Activity, and It Started Long Before the Covid-19 Crisis. It ’S Bad Enough That Patients Are Unhappy with the Care They Get. The Doctors Have No Idea How to Take Care of Themselves. Psychology Today, 53(3), 72–81.
[2] Martin J., Padierna, A., Villanueva, A. & Quintana, J.M. (2021). Evaluation of the mental health of health professionals in the COVID-19 era. What mental health conditions are our health care workers facing in the new wave of coronavirus? The International Journal of Clinical Practice, 75(10). https://doi.org/10.1111/ijcp.14607
[3] Ocampo, A. C. G., Wang, L., Kiazad, K., Restubog, S. L. D., & Ashkanasy, N. M. (2020). The relentless pursuit of perfectionism: A review of perfectionism in the workplace and an agenda for future research. Journal of Organizational Behavior, 41(2), 144 – 168.
[4] Pradarelli, J. C., Yule, S., & Smink, D. S. (2020). Performance Coaching for Practicing Surgeons Enhancing Clinical Performance, Well-Being, and Trainee Experience. Journal of Surgical Education, 77(3), 495–498. https://doi.org/10.1016/j.jsurg.2020.01.014
[5] Mache, S., Bernburg, M., Baresi, L., & Groneberg, D. A. (2016). Evaluation of self-care skills training and solution-focused counselling for health professionals in psychiatric medicine: a pilot study. International Journal of Psychiatry in Clinical Practice, 20(4), 239–244. https://doi.org/10.1080/13651501.2016.1207085
[6] Grant, A. (2017). Solution-focused cognitive-behavioral coaching for sustainable high performance and circumventing stress, fatigue, and burnout. Consulting Psychology Journal: Practice and Research, 69. 98-111. 10.1037/cpb0000086.
[7] Hullinger, A. M. and DiGirolamo, J. A. (2018). Referring a client to therapy: A set of guidelines. Retrieved from International Coach Federation website on 1st June 2020: https://coachfederation.org/app/uploads/2018/05/Whitepaper-Client-Referral.pdf
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