Burnout

In airplane safety demonstrations, we are always told to put oxygen masks on ourselves before we help others. If we are not well, how can we help others efficiently? Dr Patrick Barbara writes about burnout among Malta’s mental health professionals and what we can do to resolve this worldwide issue.

Mental health professional ‘Joe’ works in the Maltese hospital’s  services. He feels emotionally drained and at the end of his rope. In the morning, he wakes up dreading his workday. The passion for it has dissipated. Maybe, he thinks, it’s time to quit.

Dr Patrick Barbara

Dr Aloisia Camilleri and I explored the concept of burnout in professionals working within our mental health system. The research project itself was born from the notion that to support those who need care, service providers themselves need to have good mental health. 

To understand job-related burnout, it is best to see it as a spectrum. People can be happy, satisfied, and fully engaged, or they can be completely disinterested and disengaged. This framing helps us understand that there are differing degrees of burnout, while also highlighting that different definitions of burnout can lead to different results.

In our research, burnout was defined as a process where a person’s psychological resources are gradually depleted as a result of prolonged stress at work. This then manifests in emotional exhaustion, depersonalisation, and loss of personal accomplishment. The person feels worn out, fatigued, detached, and cynical about their job. Ultimately there’s a sense of inability to cope, and low morale sets in. This is the ultimate lose-lose situation where both the employee and the patients suffer as the organisation loses efficiency.

For the study, we invited 322 professionals to participate anonymously. The roles they occupied varied and included psychiatry doctors, nurses, occupational therapists, psychologists, psychotherapists, and social workers. In the end, 230 agreed to answer our standardised questionnaires. The results were in line with those of similar studies conducted abroad.

Emotional exhaustion scored highly (40.4% of respondents), as did poor personal accomplishment (30.4%). A fifth (18.3%) experienced high depersonalisation levels, while 13.9% scored high on all three features of burnout.

What causes burnout is complex and difficult to explain. The healthcare environment and the systems operating within it do tend to put healthcare workers at risk. They suffer from time pressures, emotional intensity, role conflict, and difficult relationships between employees and management.

Research suggests that people at risk of experiencing burnout often experience a mismatch between their personality and abilities and the role they are in. This mismatch is subjective, depending on the individual as much as it is related to any particular job. So while it can mean that a person has chosen a job outside of their natural abilities, it can also mean that there may be a discrepancy in expectations between the person and the organisation. So this is not just an issue of too much work. Other central elements include control, values, community, fairness, and rewards.

To prevent or resolve some of the issues associated with burnout, people need to have a sense of control at work. They need to feel rewarded (not just financially, but also socially) and treated fairly. They need to feel that they are part of a community that communicates in a civil manner and shares the same or at least similar values. Since this job-person mismatch is a subjective experience, a positive outlook towards work also helps avoid burnout. Our research showed that people who have a better ‘match’ in one factor tend to score better in the other factors as well.

So how can burnout be addressed? Awareness is the first step towards recovery. Education is essential for people to recognise and identify burnout. Practising mindfulness can prove to be an excellent tool for anyone. By becoming more in tune with our own thoughts and emotions, evaluating them in a non-judgemental way, we can avoid falling down the slippery slope towards an unhealthy mental state.

Keeping boundaries and a correct work-life balance is another point. Having time for life outside work and being passionate about other activities is critical. Whether it’s exercise, writing, or creating art, cultivating other interests keeps our worlds varied and occupied. It creates a situation where there are other things to focus on when difficult times come.

From an organisational perspective, we need to work harder to recognise that employees are the most important resource at any workplace. They need to be supported and involved in decision making as much as possible.

Burnout is linked to other mental health conditions such as depression and anxiety. Any employee who experiences mental health problems that impinge on one’s life must feel that they are not alone and help is available. Most people spend the majority of their day and life at work so we need to make sure that it is experienced as positively as possible. 

Voices for freedom and choice

Author: Dr Alexander Clayman

Dr Alexander Clayman

Abortion is a criminal offence in Malta. This means Maltese women who wish to end their pregnancy have severely limited choices. Those more affluent can pay to terminate their pregnancy abroad. Those who do not have the money can either continue the pregnancy against their will or terminate locally under unsafe conditions, risking both their health and freedom. 

Any woman who undertakes an abortion potentially faces three years in jail. Anybody who assists, such as a doctor, could also be sentenced to four years behind bars. This flies in the face of best medical practice which states that safe abortion services should be accessible to women who need them. 

A few weeks ago a group of doctors, including myself, came together to set up Doctors for Choice Malta in order to advocate for sexual and reproductive health. This includes comprehensive sex education (NOT abstinence-only education) and access to free contraception (condoms, pills, and intrauterine devices). Increased use of contraception alone results in fewer unwanted pregnancies and subsequent abortions. Putting contraceptives in the hands of comprehensively sex-educated individuals can do even more. This said, abortion still needs to be available to those people who need it. 

As a doctor, I feel I have a duty to use my knowledge and skills to better my community’s health. Together with Doctors for Choice, we are basing our efforts not on opinions or morality, but on years of medical and sociological research which shows that sex education, contraception, and accessible abortions make a society healthier. 

The irony was not lost on me when comments accusing me of being a baby-killing-mad-axe-murderer-who-doesn’t-understand-what-a-real-doctor-is started rolling in. Luckily for me, forewarned is forearmed, and the negativity failed to penetrate very deep. 

What did strike me was the contrast between the way people communicate their derision and their support. Abusive comments come in fast, prominent, and loud. Supportive comments are usually sent in private. At present, it’s clearly very easy to be openly anti-choice, but very difficult to be openly pro-choice. 

To those afraid to raise their voice and speak the truth, I say: whatever dogma, tradition, or a battalion of angry keyboard lieutenants might tell us, those who advocate for reproductive choice have nothing to be ashamed of. We are on the right side of history. 

Read more: Marston, C., & Cleland, J. (2003). Relationships between Contraception and Abortion: A Review of the Evidence. International Family Planning Perspectives, 29(1), 6. https://doi.org/10.2307/3180995

Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS ONE, 6(10), e24658. https://doi.org/10.1371/journal.pone.0024658

Heat for health

Over 10% of the Maltese population lives with type 2 diabetes mellitus. This means the local risk for peripheral arterial disease, the one that usually leads to amputation, is alarmingly high. But now, a team of researchers from the Faculty of Health Sciences (University of Malta) has its hands on a new high-tech camera that can be used to detect foot complications before it’s too late. 

A common symptom of peripheral arterial disease is a gradual temperature increase in a person’s foot. The change is very mild, making it difficult to detect manually. So Dr Alfred Gatt and his team are using the state-of-the-art thermographic FLIR thermal camera to hone in on these temperature variations from type 2 diabetes mellitus.

The camera uses infrared light in the same way a regular camera uses visible light to produce an image. Yes, puppy pictures are still possible, but they definitely won’t look as cute. Its ability to measure emitted heat means it is non-invasive, reducing risks of infection completely. So while the €30,000 price tag may seem high to some, it will save money in the long run.

The applications of this piece of equipment go above and beyond diabetes. It is being used for multiple research projects and contributing to medical knowledge related to other vascular diseases and physiological processes. Its true cost? Priceless.  

Brain Control

The power to control objects with your mind was once a dream held by science fiction fans worldwide. But is this impossible feat now becoming possible? Dr Tracey Camilleri tells Becky Catrin Jones how a team at the University of Malta (UM) is using technology to harness this ability to help people with mobility problems.Continue reading

Training to temper: Emotional learning for young people

Over the last decade, workaholics have been glorified as the epitome of success. Problem behaviour is increasingly framed as ‘interesting’ and ‘quirky’ by certain media. But as mental health and well-being capture public attention, Cassi Camilleri speaks to Prof. Carmel Cefai about his efforts to promote social and emotional learning for children and young people—skills for a lifetime.

Life is life, they say. Trial and error. You live and learn. 

But how many times have you been frustrated with yourself because you ‘never learn’ from your mistakes? 

How many times have you found yourself in a rough spot because deadlines are a dime a dozen and your to-do list is insurmountable? Your phone is ringing off the hook. All the people you have been ignoring are sending angry emails. You have not slept properly in days. All the while, you continue to dig your heels in, creating more issues with the people around you because you are so overwhelmed you cannot communicate like a decent human being. You are 40. Still think learning from experience is the only way you can go about this? 

Prof. Carmel Cefai

Human beings love patterns, routines. We love repeating what works. We also tend to repeat what doesn’t though, because change is hard. But solutions exist. At the University of Malta (UM), Prof. Carmel Cefai (Faculty for Social Wellbeing), is hard at work pushing for social and emotional education (SEE) to be promoted and strengthened at all levels in Malta and Gozo. 

His appreciation for the importance of relationships and addressing students’ emotional needs in learning started over 40 years ago when Cefai was working as a primary school teacher. ‘Getting to know the students individually, what they like, what makes them tick, providing individual attention according to their needs, was an important part of the teaching process. When I was teaching at Qormi, on Monday mornings my students and I would talk about horse racing—which horse won which race that weekend? I learnt many of the horses’ names even if I wasn’t that interested in horse racing. But then during the week we ended up using horses as examples during class. It was a good and easy way to engage students.’

Cefai agrees that while overprotecting young people is counterproductive, students should have the skills to make informed choices, avoid taking too many unsubstantiated risks, and make some but not too many mistakes. ‘We do not need to experience highly stressful, painful, or traumatic experiences to learn or grow. The process of growth does not require that we become dependent on alcohol or drugs, engage in criminal behaviour, contemplate suicide or struggle with depression.’ Playing devil’s advocate, I say that such experiences provide their own brand of wisdom, but Cefai quickly retorts that whatever the takeaway may be, even if it is a positive: ‘the price paid is much too high.’ 

Where do we begin? 

The majority of western culture, including Maltese, has a very particular problem when it comes to education—the whole process is vehemently geared towards academic achievement. There is a pervasive obsession with tests and grades. So the first thing we need to do, states Cefai, is move away from that. ‘Education is not just preparation for work. It’s also about the integration of cognitive, social, and emotional processes that make us human. If we provide an education based only on academic achievement, we will be shortchanging our children and depriving them from a good, quality preparation for adulthood,’ he says—the whole aim of education. 

Rather than what kind of jobs people do, or what successful businesses need, as educators we need to ask: what kind of life would this child or young person be happy living?

SEE is the process by which an individual develops social and emotional competence through curricular, relational, and contextual approaches, skills that can be used for personal, social, and academic development. The concept already has a proven track record, Cefai notes. Where successfully implemented, SEE ‘has already brought about a paradigm shift in education, […] transforming it into a more meaningful, relevant, and humane process.’

Malta has come a long way already over the last few decades. Cefai remembers when, as a primary school teacher, he had tried to support a young school child with mental health difficulties who was not only ridiculed and bullied by the other children, but also shunned by adults because of his ‘odd’ behaviour. ‘The boy clearly needed help from specialised professionals,’ notes Cefai. ‘But he also needed to attend school and learn with people his age. The alternative was to stay at home, which he inevitably did because he was often absent.’ Thankfully, things worked out in the end. ‘With the help of the head of school and some professionals, we managed to make some inroads and his behaviour started to improve. But I remember back then struggling with lack of professionals, fragmented services, and rampant stigmatisation.’

The situation has continued to improve since then. Cefai promptly lists the good practices which are already in place. ‘We have Personal, Social, and Careers Education which has been in schools for years now. There have been various national initiatives promoting students’ well-being, all working to prevent school bullying and violence, early school leaving and absenteeism, as well as to promote inclusion in all shapes and forms. Many colleges and schools have also been engaged in various initiatives to promote social and emotional learning, such as Circle Time, Restorative Justice and Resilience building.’ 

Not only that, but Cefai himself has worked with colleagues at the UM to found the Centre for Resilience and Socio-Emotional Health at the University, as well as with European counterparts to set up the European Network for Social and Emotional Competence. ‘Our centre has been quite active over the years in providing training for school teachers in these areas, particularly in resilience development. We are also presently working with the Ministry on SEE training of practising staff in the early years,’ he adds.  But there is still much more to be done…

Priorities 

Children’s development can be badly affected if their social and emotional well-being is not adequately addressed, says Cefai. This gap in emotional learning allows for educational systems to be driven primarily by market economy needs. Rather than what kind of jobs people do, or what successful businesses need, as educators we need to ask: what kind of life would this child or young person be happy living? The market-driven approach is focused on performance, individualism and competition, with little time and space for collaboration, sharing, compassion, and solidarity. Sadly, this situation is seen all too often. 

So, how do we fix this? How do we make SEE a priority? Cefai immediately runs off a list of to-do’s. ‘We need to give social and emotional education more space and time in our schools. We need to invest more in teachers, giving them better training, and supporting them in taking care of their own health and well-being,’ Cefai emphasises. ‘Only when teachers take care of themselves and their well-being can they really create healthy, caring classroom environments where people build healthy relationships. It’s only then that they can respond effectively to students’ needs and become good role models.’ We also need to put more effort into the early years, when the building blocks of mental health and well-being are laid. We need to encourage schools to take a more holistic approach, to give students a stronger voice, to encourage parents to take a more active, participative role in their children’s education. 

Of course this is not all achieved at the snap of our fingers. Resistance is to be expected, nods Cefai. ‘In order for SEE to work, there needs to be good quality planning, implementation, monitoring, and evaluation. We know of state-of-the-art programmes which failed to make an impact as they were not implemented well, such as the Social and Emotional Aspects of Learning (SEAL) in the UK which was eventually withdrawn because of lack of effect.’ Looking into reports about SEAL, ‘a superficial approach to implementation (‘box ticking’)’ was one of the main reasons the program failed. 

Cefai also says that we need to be careful at all stages to avoid hijacking agendas. ‘Social and emotional learning should always be centred on children and young people’s needs. Their own and others’ well-being. We need to ensure that SEE retains focus on the people it is meant to help, recognising individual differences, while avoiding labelling and pathologising children and young people. SEE is about mental health promotion and well-being and prevention, rather than on deficiencies, deficits, and illness.  Another issue is not to let SEE be taken over by the neo-liberal ’business model’ to fuel the market and global economy, where social and emotional skills are simply used to leverage productivity.’ Despite all this, the case for SEE remains tremendously strong.

There are no losers here 

A success story in SEE implementation is a success story for everyone. Reams of evidence through studies can be found touting SEE’s praises. The approach enhances prosocial behaviour and mental health and well-being. It enhances academic achievement and prevents problem behaviours such as delinquency, anxiety, and depression. Such social issues cost taxpayers money to handle, mitigate, and fix. So much so, that the costs involved in setting up SEE are guaranteed to be not only returned, but exceeded. Some studies report that for every €1 invested, €11 will be returned to the economy in various shapes and forms. 

‘I have been involved in various SEE and resilience projects in schools both in Malta and abroad,’ says Cefai. ‘I have always been very encouraged by the interest, enthusiasm, and collaboration of students, school staff, and parents. Staff and parents have been resistant at times, thinking it will take precious time from academic learning, until they realise that our approach actually enhances it. They may think that SEE is about mental illness, until they they realise that is about health and well-being and learning all rolled into one. Children really like to learn in this way, finding it enjoyable, meaningful, and useful, while teachers reap the satisfaction of seeing their students excel, improving their own lives through their contribution.’

So much of our lives are determined by our beliefs and perceptions. Learning how to process events and information in an effective way can make all the difference in how sequences of events unravel. That violent knee-jerk reaction, that long-standing bitter belief about ‘how the world works’; in difficult times, these thoughts can lead anyone down a long, dark path that’s very difficult to come back from. Social and emotional education that teaches young ones to listen to themselves and respect their feelings, as well as those of others, could begin to change that. 

In a world where we are bombarded by stimuli every waking moment, it is not hard to imagine that we need to take the time to look inward and listen—our children depend on it. 

Prof. Cefai has recently published three major publications in this area: An EU commissioned report on the integration of social and emotional education in the curriculum, an edited book on the promotion of mental health in schools and another edited book on the child and adolescent well-being and prevention of school violence. 

Read more: 

Cefai, Carmel, and Paul Cooper. Mental Health Promotion in Schools: Cross-Cultural Narratives and Perspectives. Sense Publishers, 2017.

Cefai, C. et al (2018) Strengthening Social and Emotional Education across the Curriculum in the EU.Review of the international evidence. Luxembourg: Office of the European Commission.

Author: Cassi Camilleri

Young hearts run free

For the first time in Malta, a cardiac screening programme for young people aims to identify who among them are most at risk of sudden cardiac death. Here, Laura Bonnici chats with Dr Mark Abela to learn more about the Beat It project and the impact it is having on young lives across Malta. 

There are times in life when death haunts us all. It is most tragic when it strikes down our youth. This year, Italian footballer Davide Astori and Belgian cyclist Michael Goolaerts made headlines after they died unexpectedly. Also making headlines was sudden cardiac death (SCD). 

Ischaemic heart disease is the most common cause of cardiac deaths, its likelihood increasing with age. A blockage in one of the arteries supplying the heart starves it of oxygen and nutrients, leading to heart attacks, sometimes resulting in cardiac arrest, in which there is sudden and unexpected loss of electrical heart function. But SCD in young people is very different from cardiac death later in life. 

Dr Mark Abela

Much like Astori and Goolaerts, SCD victims are generally presumed to be in good health. Early symptoms are often incorrectly attributed to other issues or life changes. The result is a horrendous loss for the sufferer and their family and friends, who also have to weather biological, psychological, and social repercussions. Seeing these events unfold, specialist trainee in Cardiology Dr Mark Abela felt the time was right to offer an SCD screening programme to young people in Malta. He called the project Beat It. 

The idea behind Beat It was inspired by the UK-based NGO Cardiac Risk in the Young [CRY], Abela notes. ‘CRY offers screening to young people between 14 and 35 to identify those who might be prone to heart disease. They then give follow-up advice, support, and evaluations accordingly. I realised that a similar programme would be very beneficial to young people here in Malta,’ says Abela. 

In Malta, the Beat It project has focused mainly on fifth form students between the ages of 14 and 16. The cardiac screenings attempt to identify those who may be susceptible to SCD, with those prone to it referred to hospital for further tests to catch the condition before it can strike.

‘Because athletes are believed to be at a higher risk for SCD, we need to have routine screening across all sporting disciplines,’ says Abela. ‘Sport has shown the medical community that young individuals who are susceptible to genetic heart disease are still at risk of SCD. Screening helps decrease this burden. Current evidence also supports that this risk is present for non-athletic youths—so why neglect these youngsters?’ 

Launched officially in October 2017, the Beat It project saw nine doctors, accompanied by a team of technicians and nurses, going into schools and running screenings. Students filled in a simple questionnaire and took an Electrocardiogram (ECG) test on the spot. ‘We analysed the results in the hope of identifying heart disease in the early stages, then advised the young people if they should consider some lifestyle changes,’ says Abela. This included advice ranging from easing up on tennis, to which career choices might be most appropriate for the student based on their health. The team also advised further medical treatment and organised follow-up appointments with specialists Dr Mark Sammut, Dr Tiziana Felice, and Dr Melanie Burg in some instances. In the end, the project screened 2,700 of the 4,300 eligible fifth form students across Maltese schools, all with the support of the school administrators and teachers, who ensured that everything ran smoothly. 

The significance of this project could also reach well beyond the lives of the young people themselves. ‘Since the country is so small and families are often inter-connected, genetic diseases in Malta tend to be more prominent,’ Abela emphasised. ‘The discovery of susceptibility to hereditary cardiac disease in any young person therefore also suggests that their parents or siblings may be at risk of SCD. With appropriate testing, the ripple effect of Beat It could preempt problems in entire families, maybe even saving someone’s life in the process.’

The project boosted awareness of cardiac disease and SCD for Maltese young people, their parents, and their teachers. UK data reports that eight out of 10 young deaths do not report symptoms beforehand. There is also a tendency for symptoms to be downplayed by educators who are not aware of potential problems. With this in mind, Beat It will also act as a learning platform. Since young people with cardiac abnormalities are at higher risk for exercise-related symptoms, physical education teachers are now more aware about potential red flags.

Celebrating the completion of the Beat It project, Abela expressed his gratitude for the team who made it possible. ‘The incredible dedication and teamwork of everyone involved has helped Beat It to effect positive change in young people’s lives, potentially saving some in the process.’  

Note: The Beat It project is a collaboration between the Cardiology Department at Mater Dei Hospital, the Ministry of Education, the University of Malta, and the Malta Heart Foundation and is supported by corporate sponsors including Cherubino Ltd.  through the Research, Innovation and Development Trust (RIDT) and TrioMed.

Author: Laura Bonnici

Blood, Genes, and You

Over the course of nine months, an entire human body is sculpted from a few cells into a baby. The blueprint is the information written into our DNA. But what happens if there is a mistake in these blueprints? Decades worth of research carried out in Malta and abroad have aimed to understand how these errors lead to a disease common in Malta and prevalent worldwide.
Scott Wilcockson talks to Dr Joseph Borg (Faculty of Health Sciences, University of Malta) to find out more.

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Why practise Taijiquan?

In the 12th century, the Shaolin Monk Chang San Feng witnessed a battle between a snake and a crane, during which the snake managed to conquer its opponent with its grace. The monk went on to formulate a set of movements, which have become the basis of Tai Chi, a martial art based on the pillars of Taoism, Confucianism and Buddhism. Taoism upholds the importance of being one with nature and the universe.

Taijiquan shares concepts with Confucianism, a system of philosophical teachings that stresses that all under the sky is one family. Everyone can be part of this great family regardless of their social status, political or religious creed. By practising Tai Chi together and sharing knowledge, participants learn and develop respect and obedience; qualities stressed by Chinese teacher and founder of Confucianism, Confucius.

During my Tai Chi classes, I like to first develop the technical aspects of a student’s movements in order for them to have a solid foundation. This is then followed by an emphasis on self-expression through movement and concentration on these movements. In the film Enter the Dragon, Bruce Lee tells his apprentice ‘like a finger pointing away to the moon. Do not concentrate on the finger or you will miss all that heavenly glory.’ At first a movement is just a movement. However, after constant practice and analysis, the practitioner realises that the movement has a rhythm behind it and this charges them with feeling, a process that resembles the way a musician feels the beat/the rhythm when performing.

The benefits of Taijiquan 

Taijiquan is a good method to alleviate stress and achieve good health. Rather than going to a gym, where a lot of energy and effort are required, with Tai Chi, a lot can be achieved without any force, and like Taoism, Tai Chi is based on the principle, known as Wu Wei (effortless effort). This means that those who practise Tai Chi should be soft and flexible in the same way that water flows smoothly. Water can take the form of any container yet on its own it is formless and shapeless.

Some scientific studies have shown Tai Chi’s benefits. One study concluded that moderate Tai Chi practice helps older people maintain fitness, while other studies showed that Tai Chi was good for a healthy and well-functioning heart, as well as to regulate blood pressure levels.

Taijiquan is based on the principle of Yin and Yang, an element of Chinese philosophy that describes how two contrary forces can be complementary. Building on this belief, those who practise the discipline try to achieve harmony which in turn brings with it good health.

The Hidden History of the Maltese Genome

By reading someone’s DNA one can tell how likely they are to develop a disease or whether they are related to the person sitting next to them. By reading a nation’s DNA one can understand why a population is more likely to develop a disease or how a population came to exist. Scott Wilcockson talks to Prof. Alex Felice, Dr Joseph Borg, and Clint Mizzi (University of Malta) about their latest project that aims to sequence the Maltese genome and what it might reveal about the origins and health of the Maltese people.

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