Beyond Emotional Labor: Exploring How Trauma Becomes an Occupational Hazard for Clinicians

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IT’S A WILD WORLD: HOW TO WORK WELL IN AN UNJUST SOCIETY

"It’s hard to get by just upon a smile.” – Wild World, Cat Stevens

My patient yells, “F*** off!” His slurred speech and his wild-eyed, glassy gaze indicate to me that, although he denies it, he is inebriated. I am trained to recognize that verbal hostility may escalate to physical violence, so my brain clocks the cuss as problematic. Get on guard. I feel my heart race, face flush, and breath quicken, and every fiber of my being wants to flee.

In the pre-COVID-19 era, I would have reached for the panic button under my desk or walked toward my office door to open it—gestures communicating to my angry patient that I am not alone. But today, despite my automatic reaction to his profanity, I remember that this is a video visit, and this virtual encounter offers one solace—today, this patient’s behavior cannot escalate to assault. In the moment it takes for me to register that I am safe, I feel a burden lift and I become cognizant of a weight I have been carrying for over 2 decades. This baggage is a result of the distress that goes with exposure to verbal abuse and hostility at work.

Over 40 years ago, Berkeley sociologist Arlie Hochschild coined the term emotional labor to describe the work done by an employee to manage their personal feelings in order to fulfill the requirements of a job.¹ Health care is an industry that requires clinicians to carry heavy emotional labor loads, and this labor has been identified as a job stressor contributing to burnout.² As I ended my video visit with my irritable and intoxicated patient, I could feel the emotional labor required for me to ignore his swearing, restore an empathic connection, and close the call in a professional manner. Yet I also recognized, perhaps for the first time, the burden of a greater labor, a toil with traumatic roots, that I call trauma labor.

In the beginning of my career, I had viewed exposure to abuse in the workplace as coming with the territory of psychiatry. This is not because individuals living with mental illness are inherently dangerous, rather I knew that when humans are psychotic, suicidal, homicidal, or under the influence of drugs or alcohol, they may behave in belligerent ways. To safeguard against this, I have always taken precautions: every office I occupy undergoes a furniture reshuffle, with my chair closest to the door; I am trained in managing disruptive behavior and after long shifts, I walk to my vehicle clutching a panic alarm. In terms of personal attire, necklaces and scarves are banished from my wardrobe, and I rarely wear shoes in which I cannot run.

By the time I was deep into my first decade of doctoring, 1 thing was abundantly clear: believing that violence at work was comprised of isolated incidents was wishful thinking. Workplace violence (which includes verbal abuse, hostility, and harassment) is a systemic issue in health care, with a 2015 OSHA report showing incidents of serious workplace violence were 4 times more common in health care than in private industry and that possible sources of violence went beyond patients to encompass family members, intruders, and even coworkers.³

While workplace violence affects all health care workers, women are disproportionately impacted.⁴ On March 9th, 2018, at the Pathway Home program for returning veterans in Yountville, 3 women—Christine Loeber, a social worker; Dr Jennifer Gonzales, a psychologist who was 6 months pregnant; and Dr Jennifer Golick, the program’s clinical director—were murdered by a former patient.⁵ This horrific tragedy shook me to my core and, in the aftermath, many intense conversations with female colleagues ensued which made me realize I was not alone and many of us were feeling the toll of years of exposure to abuse and hostility at work. These conversations raised many questions: Were women subjected to more abuse at work because we live in a world where violence, against women, is pervasive?⁶ Are women more disproportionately burdened with the stress of workplace abuse because we are programmed to be more afraid for our physical safety when compared with our male colleagues? Are women more at risk because we are overrepresented on the frontlines in healthcare and underrepresented in the leadership of health care institutions (where policies surrounding health care violence are set)?⁷ These discussions also reminded me of the even greater vulnerabilities of women health care workers with less education, less pay, and job security, who often find themselves working in particularly precarious and unsafe settings.

I believe we need to go beyond the concept of emotional labor and consider the notion of trauma labor, a toil that employees have to endure that has historical roots embedded in traumatic social constructs such as misogyny. Trauma labor requires me to manage my emotions and fulfill my workplace duties when my identity may be contributing to why I am being mistreated in the first place. Would my inebriated patient have told me to f*** off if I was male? Of course, I will never know the answer to that question, so I am left with only a hunch that my identity is related to such hostile workplace incidents. In this way, trauma labor becomes further complicated by a discomforting ambiguity because even if the abuse is unrelated to misogyny, it still imposes this burden of consideration. I believe trauma labor impacts clinicians from all groups that have been historically marginalized. They are inherently vulnerable to identity-based mistreatment as they go about their day-to-day work. The labor requires that they stay professional despite the toll the mistreatment takes on their personal well-being. My anecdotal experience leads me to believe, that like emotional labor, this “trauma labor” is playing a hidden role in the clinician burnout epidemic that is gripping our profession. This predicament in further exacerbated by the fact that violence at work remains underreported, by health care workers, for many reasons including lack of clearcut policies, navigating reporting systems is onerous, lack of faith in the effectiveness of such systems, and a fear of retaliation.³

Toward Alleviating the Toll of Workplace Verbal Abuse and Hostility

The following suggestions are not a solution but a start to addressing the problem of trauma labor and workplace violence and mistreatment. They represent small steps on a path toward ensuring career longevity and prosperity in our wild world.

For individual clinicians:

1. The attitude of “it is your job to take it” currently embedded in health care ethos needs to be eradicated. If you have internalized this ethos now may be the time to reexamine it. If you tend to want to be a hero or a martyr, keep that in check. That trait will not serve you well under such circumstances.

2. The statistics suggest you are not alone. Do not suffer in silence when such incidents occur. Access the support and validation of trusted colleagues and reach out to mentors and supervisors for guidance on how to process or navigate such incidents.

3. If you have faith in your workplace reporting system of such incidents, then use it. Better still, volunteer to serve as a clinician member on any related committees and get ready to speak truth to power.

For colleagues and coworkers:

4. Tolerance for verbal abuse and hostility toward health care professionals should became antithetical to the collective values of all health care professionals.

For health care leaders:

5. Recognize that violence against female clinicians in the workplace undermines their abilities to progress in careers or be promoted to leadership positions from which they could bring a diverse viewpoint to effectively addressing workplace violence prevention policies.⁴

6. Violence at work leads to burnout and moral distress and absenteeism and attrition and leadership failure to address this issue will likely contribute to the global shortfall of health care workers.⁴

For institutional leaders:

7. Health care institutions need to take a top down and zero-tolerance stance toward identity-based attacks on frontline clinicians. Zero tolerance should go beyond rhetoric to actual safeguards and enforceable policies that become seamlessly and tightly woven into organizational culture.

8. Violence reporting systems of the hospitals should be clinician centered and accessible and not pose an undue burden on the clinician victim.

Dr Jain is a board-certified general psychiatrist, with specialty expertise in PTSD, primary and mental health integrated care, and women’s health psychiatry. From 2012-2020, she served as Medical Director for Integrated Care at the VA Palo Alto Healthcare System and is also a former health services researcher, affiliated with the National Center for PTSD. She is an adjunct clinical professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine and a distinguished fellow of the American Psychiatric Association and the author of The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science (Harper, 2019).

The views expressed are those of the author and do not necessarily reflect the official policy or position of the organizations with which she is affiliated.

References

1. Hochschild AR. The Managed Heart: Commercialization of Human Feeling. University of California Press; 2012.

2. Jeung DY, Kim C, Chang SJ. Emotional labor and burnout: a review of the literature. Yonsei Med J. 2018;59(2):187-193.

3. Workplace Violence in Healthcare: Understanding the Challenge. Occupational Safety and Health Administration. Accessed October 25, 2024. https://www.osha.gov/sites/default/files/OSHA3826.pdf

4. George AS, McConville FE, de Vries S, et al. Violence against female health workers is tip of iceberg of gender power imbalances. BMJ. 2020;371:m3546.

5. Vera A. Victims of California veterans home shooting lived ‘to serve others.’ CNN. March 11, 2018. Accessed October 25, 2024. https://www.cnn.com/2018/03/10/us/california-veterans-home-shooting-victims/index.html

6. Heise L, Ellsberg M, Gottmoeller M. A global overview of gender-based violence. Int J Gynaecol Obstet. 2002;78 Suppl 1:S5–S14.

7. The state of women and leadership in global health. Women in Global Health. March 16, 2023. Accessed October 25, 2024. https://womeningh.org/wp-content/uploads/2023/03/The-State-of-Women-and-Leadership-in-Global-Health.pdf