What mental health needs is more sunlight, more candour, and more unashamed conversation.
–Glenn Close, actress and founder of mental health charity Bring Change to Mind
A dental professional wears many hats: a mechanic, artist, educator, leader, life‐long learner, sometimes a counsellor, and, at the heart of all roles, a caregiver. We are in the privileged position to help guide positive behaviour change. From building preventative oral hygiene habits to smoking cessation and reducing the frequency of sugary attacks, dental professionals are in the business of helping patients with their physical and mental well‐being. The high demands on this role require considerable clinician resilience and well‐being.
As dental students, one of the first pivotal principles taught to us is that prevention is better than cure. In this book, we explore exactly that: the case for clinician well‐being training before we are ill. Chapter 1 kicks off this conversation with delving deep into mental health in dentistry. We explore the mental health continuum, the current mental health of dental professionals, occupational hazards, the psychology of stress, and the need to train the mind muscles.
Understanding the Mental Health Continuum
Mental health is a dynamic process and is always shifting. More than simply a lack of mental disorder, the World Health Organization (WHO) defines mental health as a ‘state of well‐being whereby individuals recognise their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities’ (WHO 2004). A crucial factor in the case for preventative clinician training is that are we are all on the mental health continuum. Imagine one end of this continuum representing minimum mental fitness (lower levels of mental health and resilience) and the other end representing maximum mental fitness (high levels of mental health and resilience). Our starting point is somewhere on this continuum dependent on our genetic makeup (see Figure 1.1).
Positive and negative life outcomes also impact whether we shift up and down this continuum. Both our genetics and life’s events are not within our direct control. What we can influence, however, are our protective and risk factors and hence encourage a positive movement towards better mental well‐being despite adversities. Table 1.1 illustrates the factors that influence mental health. While we will always be shifting up and down the continuum, we can take active steps to keep us mentally fit. This book focuses on how you can boost your levels of protective factors and encourage shifting towards maximum mental well‐being.
Table 1.1 Risk and protective factors influencing our mental health.
|Risk factors||Protective factors|
Pessimistic thinking style
Lack of positive coping skills
Lack of exercise
Traumatic life events
Lack of social support
Lack of meaning
Strong social network
Values and beliefs
Understanding the Stressors in Dentistry
Dentistry is a profession that is historically well known for its stressors. The origins of stress are already present, prior to qualifying. This is in part due to the high academic pressures of an intensive five‐year programme paired with the early introduction of clinical care (Newton et al. 1994). Table 1.2 sums up the common factors stated in the literature.
Table 1.2 Stressors in dentistry.
Stress, Evolution, and the Chimp
What happens to the brain when we immediately receive stressful news? For us to understand the internal processes of the brain, Steve Peters offers an excellent simplified view (Figure 1.2). In his seminal book The Chimp Paradox, Peters divides the brain into three parts. The ‘chimp’ represents the amygdala, the oldest part of the brain, which evolved purely to keep us safe and where the ‘fight, flight, or freeze’ response resides. It is an emotional and irrational part of the brain. The ‘human’, representing the frontal lobe, is the logical, problem‐solving part of the brain concerned with thriving. Thirdly, the ‘computer’, representing the parietal lobe, is where our automatic programmes, beliefs, and experiences are created and can be viewed as our habits.
Whenever there is a stressor, the first port of call is our ‘chimp’ (the emotional brain) and then the ‘human’ (the thinking brain) secondly. This is known as the amygdala hijack. The ‘chimp’ was crucial in times we were escaping sabre‐toothed tigers and was developed to be highly attuned to stress. These stressors now are no longer real threats to our physical safety. Instead, we face social media, fear of litigation, news that someone else in another part of the country is getting sued, a demanding patient, or an ambiguous call from the practice manager.
Taking Back Control
Psychologists Susan Folkman and Richard Lazarus studied the interaction of individuals with their environment, specifically considering the thinking (cognitive) approaches to stress, in their Coping Theory model (Lazarus and Folkman 1984). This model explores the dynamic relationship between stress and our coping strategies (Figure 1.3). Coping Theory reminds us that we can get control of stressful situations, using helpful coping strategies, whether they are focused on the problem in hand or on our emotional reaction to it.
When we receive a stressor, whether this is work related or at home, we first appraise the situation in terms of whether it may cause us harm, threat, or a challenge (primary appraisal). We then move onto a second appraisal where we assess if we can cope with the stressor. We do this by considering various coping options to best change the situation (coping response). Problem‐focused coping attempts to change the stress by practical means. If this is not possible, emotion‐focused coping aims to reduce our negative emotional state. Both problem‐ and emotion‐focused coping styles are helpful, dependent on the situation. The third category of coping style is avoidance, and as the name suggests, it is unhelpful (in the long term)! See Figure 1.4 for examples for each coping style.
Chronic Stress: A Recipe for a Frazzled Brain
As we discussed in the previous section, our brain has evolved to manage an immediate response to imminent danger. As the Yerkes–Dodson Curve describes, a certain amount of stress can be helpful in making us feel energised. But what does chronic stress do to our brains? Neuroscience research of the brain and stress reveal that chronic stress physically changes the structure and function of our brain. The chronic stressors dental professionals face in the workplace dangerously deregulate a system built only to deal with short‐term responses.
Burnout and Compassion Fatigue
As with our other healthcare comrades, burnout and compassion fatigue are occupational hazards of the role. Both are risk factors for depression and anxiety, suicide, alcohol and drug misuse, patient errors, strained work relationships, patient dissatisfaction, and attrition (Lacy and Chan 2018).
Burnout is defined as chronic workplace stress where we are unable to meet constant demands (World Health Organization 2019) and is as high as 30% of dental clinicians (Toon et al. 2019). It often develops at undergraduate level and presents as a higher risk in dental students compared with other university students (Collin et al. 2020). Clinician burnout is problematic in severely impacting our well‐being, professional efficacy, and ability to look after patients.
Burnout can be thought as a three‐dimensional construct incorporating high emotional exhaustion, high depersonalisation and low levels of personal accomplishment’ (Maslach and Jackson 1986). Depersonalisation refers to a reduced engagement with one’s life; a psychological withdrawal from relationships and the development of a negative, cynical attitude. Dental professionals early on in their careers may be at increased susceptibility to depersonalisation and work–life conflicts. Research on medical professionals also highlights that traits of perfectionism and extreme dedication to providing exceptional care may compel healthcare professionals to prioritise professional duties disproportionately over time spent maintaining their own well‐being. Emotional exhaustion refers to feeling very low in energy, a deep exhaustion not resolved with rest, and a reduced ability to feel empathy. As a dental professional, empathy is one of our prized values, and this greatly impacts our communication and ability to connect with our patients. Reduced personal accomplishment in the context of dentistry is the loss of feeling like the work you are doing is worthwhile and helps patients.
A simplified way to remember the signs and symptoms of burnout is to break down its impact on our thoughts, feelings, and actions (see Figure 1.5). The thoughts that characterise burnout are deep cynicism related to work and hopelessness and being self‐critical in nature, such as ‘what’s the point in trying, I’m never good enough’, ‘I’m not a good dentist’, ‘my patients/co‐workers don’t care about the hard work I’m doing’. Dental professionals may feel incompetent, inefficient, and unable to complete tasks. The thoughts often present in a ruminative fashion, an endless loop of excessive worry and a decrease in focus. In terms of the emotional impact of burnout, there is a severe emotional exhaustion. Energy levels are grossly depleted, and burnt‐out dental professionals feel a reduced ability to feel empathy. The latter is particularly critical when working within dentistry, as our ability to connect to our patients with compassion is diminished. And lastly, the impact of burnout on our behaviours includes taking time off (absenteeism), inability to work or be productive on days when we come into clinic (presenteeism), and leaning towards unhelpful coping strategies, such as substance abuse. We can see from Figure 1.5 that burnout impacts how we think, how we feel, and our actions. For this reason, it is imperative we value, understand and actively train the mind muscles of resilience.