Jessica A. Alexander, M.D

“Two are better than one,
because they have a reward for their toil.
For if they fall, one will lift up the other;
But woe to one who is alone
and falls and does not have another to help.
Again, if two lie together, they keep warm;
but how can one keep warm alone?
And though one might prevail against another,
two will withstand one.
A threefold cord is not quickly broken.”

— Ecclesiastes 4:9-12

ne of the many social “ailments” that faces the countless, nameless masses is isolation from others. The reasons may vary, but the loneliness that ensues may contribute to chronic stress. It is a well-known fact that if babies are left completely alone at birth, they will likely suffer from “failure to thrive” and can actually die if they are not held and nurtured as part of their basic care; this may occur even if their other basic needs are met, e.g. food, shelter and clean clothing. While we as adults are not known to die from the same affliction, our bodily and our psychological health are still dependent on our healthy and appropriate physical and emotional enmeshment with others. Two independent university studies found that premature death occurs at twice the rate in adults who are isolated and do not cultivate friendships. The impact of the isolation described in these studies is considered to be the equivalent of the effects of hypertension, hypercholesterolemia, obesity and/or lack of physical exercise.¹

Many adults find themselves alone or isolated as a result of burnout or stress. In today’s world, more often than not, our first line of communication is nonpersonal in almost every facet of our daily existence: We suffer through multiple and annoying computer voice selections just to reach an operator (person) at a department store, we text message instead of talking, use ATMs instead of interacting with a bank teller, and we utilize all manner of cold, alienating and people-eliminating methods to communicate with each other. Even something as simple as booking a plane flight or as complicated as booking a month-long safari with our local travel agent is done “online.” We are financially penalized for using a person rather than a computer to perform either of these tasks and, likewise, if we want a “paper” plane ticket. Even in a perfect world, most of us have less communication with those whom we consider very important in our lives than we might have had even a decade ago. That is in a perfect world. Most of us don’t live in our idea of a perfect environment, either at work or at home or both.

This is an “egg or chicken” conundrum: It is not known whether being isolated is a symptom of burnout or a condition that leads to burnout and/or stress. Social scientists do know that one of the most primitive actions that humans strive for is connection. We are actually born with “an insatiable inner need for meaningful interaction with others.”² When there is a lack of meaningful personal attachments in our everyday lives, we suffer — some individuals more than others.

The total social context in which we live dictates our response to lack or loss of personal relationships. In other words, this part of the stress response doesn’t occur in a vacuum. Many of life’s other stressors (discussed in a previous article by the author in the November 2000 ASA NEWSLETTER) may contribute to how someone deals with the particulars of their personal relationships. The loss of such attachments, however, may be one of the most profound symptoms or causes of stress and burnout.

“Intimate attachments to other human beings are the hub around which a person’s life revolves.”

—John Bowby

Why Do We Find Ourselves Isolated?
Despite previous perceptions and plain simple dogma, social scientists now believe that burnout occurs most commonly as a result of the breakdown in the social context of the workplace environment, not because of flaws in the individual. Maslach hypothesizes that it is an individual’s efficiency and an ability to control his/her work surroundings that determines response to stress. More importantly we now know that the more significant factor in managing stress is the structure of the organization and its ability to allow each person to interact productively within the organization and with each other. Perhaps the most important fact in this restatement of how the “organization” may be the “culprit” in an individual’s stress response is that it does not appear to preferentially affect those with any particular place in the hierarchy of that “organization.” The loss of an organization’s ability to “treat its employees with humanity leads to a loss or erosion of the soul.” Maslach further describes burnout as “the index of the dislocation between what people are and what they have to do.” This erosion of “humanity” includes a loss of values, dignity, spirit and will.

Maslach’s description of a triad of emotional exhaustion, cynicism/depersonalization and a feeling of ineffectiveness or perceived lack of personal accomplishment paints the modern picture of burnout as most people experience it in today’s already detached society.³ As individuals tend to fall into this “Bermuda Triangle,” it is not just a psychological morass; it is possibly a matter of life and death.

How Do We Recognize When We Are Burned Out?
It is not unusual for an individual to ignore or simply not recognize the signs and symptoms of burnout until they are physically, mentally and/or emotionally at risk. When someone is faced with the loss of control — one of the outward manifestations of stress — that individual can become overwhelmed by stress hormones that accompany exhaustion. Their physical health may be threatened. These hormones represent the “fight or flight” response, which over time can lead to a plethora of medical problems that may include hypertension, heart disease, headaches, chronic fatigue even with adequate sleep, or chronic sleeping or insomnia, among many other maladies.

Additionally pathologic emotional issues such as anxiety, depression, sleep disturbance and/or anger and aggression may accompany the physical symptoms. These may progress to increased thoughts of death or suicide. If we bring our burnout home (which is hard not to do!), it is not unusual for our relationships to suffer, particularly with those whom we love the most. Any “toxic” relationships in which we may be involved tend to deteriorate or in some cases to insidiously “poison” those involved. If you are in “burnout,” you may find it more and more difficult to control interactions in these unhealthy situations, many of which may need to be severed.

When individuals are in full “burnout,” they may start to isolate themselves from or avoid interaction with others. Social opportunities and invitations to spend time with family, friends and/or relatives may start to feel like “traps” from which they feel the need to withdraw or even “cages” from which they respond to in recoil. They may start dreading going to work or feeling like work is a “dead end.”

Substance abuse or other compulsive behaviors, including over-work, are not unusual. Even if “work-aholism” is part of our burnout pattern, we may have a sense that we are accomplishing less despite seeming to work harder. We may find ourselves involved in a dysfunctional work environment, including team interaction failure (e.g., with our anesthesia care team), partnership issues, trans-generational problems (old versus new partners) and call or work-sharing issues.

If we start to make patient care errors or to question our ability to perform our work without incident, we have to act immediately to reassess our status. If we fail to do so, that intervention may be done for us, usually after a sentinel event occurs. It is imperative to inventory our lives to avoid getting to this point.

Why Is It Important to Look at the Quality of Our Relationships?
It is a given that all of us have a very limited amount of time to spend on relationships. Yet connections to one another are literally our lifeline to a long and happy life. Jeffery Gitomer has said: “I’ve heard the saying: ‘There’s only two big decisions in life, where you’re going, and who you’re going to take with you.’” This is so true. It is important to spend time with the people who are “traveling” with us; without this time together, we do not get the emotional support that we need to remain healthy. It is therefore essential to constantly assess the quality of our relationships and friendships, to eliminate those that are no longer working, and to refresh those that are indispensable to our emotional health.

How Do We Optimize Our Ability to Make and Keep Quality Friends?
Any type of personal relationship, whether romantic, collegial or those in our intimate circle of “best” friends, depends on the same basic tenets. The relationships that we choose to nurture require attention and careful selection. At a minimum, they all involve good listening skills, the type of listening that the late psychologist Carl Rogers called “growth-promoting.” This involves the ability to convey an authentic interest in what the other has to say and the ability to empathize. It also includes the ability to reciprocate without overwhelming the other. True friendship doesn’t include keeping score in any context or at any level. There is an understood belief that “what goes around comes around,” that we will eventually get back what we put in. If the relationships in your life don’t seem to fit within these parameters, reassessment of their worth is essential.

Conclusion
The take-home message is that none of us will lead healthy lives without close connection to others. When circumstances occur that may cause us to find ourselves “circling the drain” of burnout, these connections may suffer and sometimes fail. Without nourishment, we may lose the greatest lifeline(s) that we (hopefully) have to draw us back. The qualities of loyalty, forgiveness, honesty, dedication, commitment and personal sacrifice allow us to weather the bumps in the road with any true friend; for without these qualities, we will likely be unable to sustain meaningful friendships for the long haul. The absence of these important connections may literally mean the difference between life and death for any one of us at any time.

“Be courteous to all, but intimate with few, and let those few be well tried before you give them your confidence.

“True friendship is a plant of slow growth and must undergo and withstand the shocks of adversity before it is entitled to the appellation.”

— George Washington

References:
1. Smith DW. Men Without Friends. Nashville: Nelson; 1990:46-47.
2. Parrott L, Parrott L. Relationships. Grand Rapids, Michigan: Zondervan; 1998:15.
3. Maslach C, Leiter MP. The Truth About Burnout. San Francisco: Josey-Bass; 1997.

Jessica A. Alexander, M.D., is Clinical Professor of Anesthesiology, University of Texas Health Science Center, San Antonio, Texas.