The metamorphosis: On being caterpillars and butterflies

A recent Debate article by Agalawatta et al. (2020) outlines several important issues faced by those completing the fellowship training in the public sector. As early career psychiatrists who have recently metamorphosised from caterpillars to butterflies, we also faced many of the challenges described in the Debate. We dealt with the challenges in different ways and places (i.e. collectively, we have worked in the private sector and public system as well as temporary locum positions). The Debate article (Agalawatta et al., 2020) made us reflect on why it’s hard to be a butterfly, and we collate our reflections here in the context of moral injury.

Moral injury

Dean et al. (2019) propose that clinician distress should be re-conceptualised as moral injury rather than burnout. The concept of moral injury, originally proposed by a psychiatrist Jonathan Shay, arises from an observation of Vietnam War Veterans. Among those who presented with symptoms of posttraumatic stress disorder (PTSD), there was a subgroup of veterans who did not respond to standard care and experienced symptoms outside of typical PTSD criteria. While those with the ‘classic PTSD’ experienced a threat to their mortality, those with the atypical presentation experienced repeated insult to their morality. Individuals with ‘classic PTSD’ returned home concerned for their physical safety, but those with atypical PTSD returned home questioning whether they were still moral beings. Moral injury is defined in the health setting as ‘the challenge of simultaneously knowing the care patients need but being unable to provide it due to constraints that are beyond our control’ (Dean et al., 2019). Moral injury is a result of a broken system. The concept of moral injury puts the cause of clinician distress in the system, not in individuals who work in the system.

Public mental health system

The framework for mental health services in Australia is complex. We have a mixture of public and private systems, with funding shared between federal and state governments and insurers. While the private mental health sector provides a significant portion of mental health care provision, the public system is tasked as the default care provider for all. Because of this, psychiatrists in the public mental health system often need to act as watchmen/watchwomen tasked with resource allocation. Some may argue that we, as gatekeepers, should advocate for the best patient care and place the onus of gatekeeping on administrators. This is particularly challenging for early career psychiatrists. Many of us have little experience in having to act as a gatekeeper to an insufficiently resourced system during our training. As clinicians with duty of care and training that emphasises the idea of evidence-based medicine, public psychiatrists are prone to experiencing ‘moral injury’. For example, when you arrive at work on Monday, you are asked to discharge a woman with borderline personality disorder with possible comorbid depressive illness. Even though she is still presenting with significant distress and high risk of suicide, you tell yourself that a prolonged stay may be counter-therapeutic, and discharge her with a recommendation of Dialectical Behaviour Therapy, being fully aware that she is likely to have limited availability or financial means to access the intervention. Is a prolonged stay counter-therapeutic if we have limited follow up after the discharge, or is it a post hoc rationalisation? We have become comfortable followers of the guidelines and protocols, but we often lack the experience, flexibility or organisational support to put the evidence in the context for each individual patient (Greenhalgh et al., 2014). This shortfall can not only lead to the niggling feeling of we should be doing better, but may also result in care provision that is characterised by a series of tick box exercises driven by operational key performance indicators with tokenistic treatment recommendations that ignore the context and complexity. In other words, an approach that is neither evidence-based nor patient-centred. Instead of simultaneously knowing the care patients need but being unable to provide it, we often find ourselves simultaneously feeling uncertain about the care patients need and being unprepared to embrace the uncertainties.

We have previously argued that psychiatrists are particularly vulnerable to experiencing clinician distress due to various factors that are unique to our profession (Kim et al., 2019). These include patient violence and suicide, as well as possessing responsibility without requisite authority in many instances (e.g. forensic orders; Suetani et al., 2019). These issues were also echoed in the Debate article (Agalawatta et al., 2020). In addition, we often face dilemmas of differential responsibility such as the question of covering for service gaps to be seen as a team player or declining this to protect one’s own welfare. If not addressed appropriately, these issues lead to a significant negative impact on patient care and professionalism, threatening the viability of the public mental health system.

Who will watch the watchmen?

The conceptual shift from burnout to moral injury is critical. If the underlying issues of clinician distress reside in the system, then the solution should start with addressing the system, not the individuals who are in the broken system. But who will watch the watchmen – early career psychiatrists who find themselves in the unfamiliar role of being a gatekeeper? To promote and protect psychiatrists’ welfare in the public mental health system, there needs to be an investment in people and resources (Dean et al., 2019). In practical terms, administrators should be evaluated according to staff satisfaction (e.g. recruitment and retainment rates, trainee progression) in addition to operational key performance indicators. While it is hard to quantify things like moral and work culture, both psychiatrists and trainees often vote with our feet. We also acknowledge the challenging work being done by these watchmen and watchwomen in a stretched system. We share the existential burden experienced from feeling like failing despite best intentions. Critical aspects of the demoralisation include the sense of helplessness, hopelessness and lack of recognition of the work done. In public mental health, we are all unavoidably part of a greater system. An understanding, and an acceptance, of the system and the historical reasons for its flaws may be useful. For instance, receiving external supervision from a senior psychiatrist/mentor outside of the service, or discussion with a supervisor/director of training, and peer review group to help trainees understand systemic issues may be helpful in this aspect.

Conclusion

Let us return to the metaphor of metamorphosis. Butterflies are short-lived and ungrounded – their purpose is to leave their area of origin to lay eggs in a new territory. Even though they serve a useful function as a pollinator, they do not improve their area of origin. Caterpillars, on the other hand, are grounded in the area on which they were born, they work that area and are engineers of the ecosystem. Perhaps the problem in our training – and public psychiatry – is that we make our caterpillars want to fly away. To promote and protect psychiatrists’ welfare in the public mental health system, we need to re-conceptualise clinician distress and its antecedents. Instead of focusing on preventing burnout (or opt-out) in early career psychiatrists, we need to address the underlying problems that are leading them to opt out of (or burn out in) the public health system.