Caring for those Who Care for Our Pets

• Stresses on the Veterinarian
• Addressing the Need
• Case Discussion

Stresses on the Veterinarian

We can’t turn on the television or look at social media without seeing evidence of how the pet industry has grown exponentially over the years. We don’t just have pets anymore; we now are the proud parents (and grandparents) of “fur babies.” Rarely, however, do we think about the difficult side of having a fur baby. Yet veterinarians are on the front lines of managing the effects of this fur baby boom; and, as pets age or become ill, veterinarians have the difficult task of working with pet parents and providing the necessary care for their pets. This task, difficult on its own, is compounded when pet owners cannot afford or are astounded by and react intensely about their pets’ cost of care. Still other pet parents are unable or unwilling to accept their pet’s illness and insist on providing treatment, even when the treatment will not extend the animal’s life. Even with these tensions, veterinarians often develop an emotional connection with pet owners and their pets. The emotional connection adds a dimension of stress and emotional pain when pets become ill or must be euthanized. Being a veterinarian is far more than working with animals.

Then there are the kinds of stories that appall the public. In early 2020 in South Florida, it was reported that a local humane society euthanized 198 animals over a two-month period without first requesting any support from rescue groups. The story is certainly shocking, and the tragedy to the animals pulls hard on our heartstrings; yet we don’t consider the impact of situations like this on shelter veterinarians. For this group, the need to euthanize can be emotionally overwhelming, given the number of euthanasia procedures they must perform due to overpopulation.

A review of the literature suggests that there is some training to help veterinarians provide grief support services and resources to clients. Still, there is little available to veterinarians for their own work-related grief work. An example of the need for awareness in this area was noted when one of the authors’ dogs, Riley, had to be euthanized when medications to control his health issues were no longer effective. Riley had been a client at his vet’s practice for seven years, and the hospital staff was also affected by the need to euthanize him. While there is the need to maintain a professional stance in these cases, it is important to note that veterinarians and their staff may have strong feelings for their clients.

Over the last couple of years, we have come to see that, like others in the helping professions, veterinarians face a wide variety of stressors that contribute to issues related to their mental health. Because impairments manifest in varying degrees, it can be challenging to recognize one’s own or a colleague’s impairment, even in the best of times and with experience. This is of particular concern when we consider that this group of professionals is at higher than average risk for suicide.

According to reports from the CDC and other international studies of veterinary professionals, mental health issues amongst veterinarians can be attributed to multiple factors. Compassion fatigue, demands for euthanasia, challenges with workplace relationships, and the demands of supporting and educating pet parents on issues related to their pets all impact veterinary professionals’ mental health. The responsibilities of managing a veterinary practice and exceedingly high levels of veterinary school debt from tuition costs averaging $160,000-$329,000 add additional burdens to veterinarians’ already stressed and challenging careers. Given our current COVID-19 crisis, many veterinarians have been furloughed or laid off or are witnessing their colleagues being laid off, creating a new level of stress. In addition, veterinary office changes were required to help manage physical distancing during COVID-19, causing stress for both veterinarians and pet owners.

While client relationships are primary in veterinary medicine, veterinary practices are also production-based, meaning that the veterinarian must manage what is in the best interest of the pet/client and the need to produce to retain their position. This creates an ethical challenge. In addition, the level of rigor and oversight around medical documentation can vary, with some practices being flexible and accommodating about how documentation is kept and who can sign off on medical records. Some practices allow technicians to sign records for renewing prescriptions or completing medical notes; this can open opportunities for veterinary staff to illicitly take or prescribe medications.

When combining the immense stressors that contribute to depression and other mental health-related issues, a production-based work environment, lax or variable management of documentation, and workplace access to a wide variety of drugs, many of which are highly addictive, there is increased potential for veterinary professionals to become susceptible to drug misuse and addiction to cope with work stress. Dr. Jon Geller noted this danger in his 2016 article in DMV 360 and added that there are insufficient resources to address this concern, including insufficient drug testing in veterinary workplaces, few or inadequate drug control procedures, and limited access to or availability to employee assistance programs.

Veterinarians have access, often with limited oversight, to potentially addictive medications to help with depression, anxiety, and sleep management. While increased levels of scrutiny and oversight have limited opportunities for medical professionals working with human patients to access in-house drugs, this level of oversight has not been implemented in veterinary practices in the United States.

The importance of greater training around and support for prescription abuse for veterinarians is underscored in stories such as John Burke’s Pharmacy Times article (2019), which highlighted the implications of limited oversight in veterinary clinics. As Burke relays, as rates of addiction rise with the growing opioid crisis, there is an increasing need for veterinarians to receive training and support around prescription abuse. His article includes an account of a veterinarian who prescribed unnecessary opioid medications for pets she had placed under overnight observation; pet owners would fill the scripts and return the medications to the clinic for their pets, not knowing that the veterinarian was taking them for herself. This practice continued until a pharmacist learned that the drugs were being returned to the vet clinic for administration and reported it to the authorities.

Addressing the Need

Given these challenges, the increased attention to veterinary professionals’ mental health needs is both timely and necessary. Yet, according to the American Veterinary Medical Association, only 36 states and the District of Columbia have laws and regulations authorizing wellbeing programs for veterinary professionals. Once it is determined that a veterinarian is indeed heading in the direction of impairment, because of the taboo associated with “having” a mental health or substance use disorder, it is often difficult for colleagues to encourage the impaired professional to seek counseling. Seeking the right treatment is important to maintain professional competence. By developing interventions for veterinary professionals along the three levels of prevention (primary, secondary, and tertiary), mental health professionals can intentionally make connections with and offer support to veterinarians. These prevention services can include education, training, and support around mental health and substance use disorders that are focused specifically on the issues faced by veterinarians.


Primary Prevention Interventions

Veterinary training programs may serve as ideal grounds for implementation of primary prevention strategies, which aim to address prevention of mental health and substance use issues before they arise. In many ways, to address the needs of veterinarians, it just makes sense to meet their needs when these professionals are at their most energetic and idealistic—while they are students, before the stressors of the work really start to impact professionals’ mental health. Clinical training faculty; however, may not sufficiently focus on students’ mental health or stress the importance of self-care during training. And conversely, students in these high pressure training programs may be reluctant to admit to that they are struggling emotionally. In a school-based primary prevention intervention, mental health professionals might coordinate with veterinary programs to offer workshops or guest lectures during various points in students’ training to reduce the risk of mental health disorders and/or substance use disorders. Integration of mental health information should not be a one-time occurrence. Instead, this type of programming should be implemented from the initiation of coursework as a prevention strategy for students while they deal with the stress and pressure of training.

A primary prevention strategy also offers an opportunity to plant seeds for when the student is a professional working in the field. In this case, mental health professionals could provide services that educate educators and students in veterinary studies about mental health and substance use disorders as well as the factors that often affect these impairments. Such training should also help educators and students identify the potential signs and symptoms of the impairments. Moving beyond just providing factual information, mental health professionals could work collaboratively with veterinary education programs to develop prevention programs that address and mitigate risks for mental health and substance use disorders amongst students. These programs could include interventions to help students develop self-care strategies, connect students to resources in the community, and support the development of healthy relationships within students’ support networks.


Secondary Prevention Interventions

Secondary prevention strategies involve early detection of issues, usually through screening measures. One example of a secondary prevention intervention would be mental health providers’ working with veterinary professionals to help them recognize when they or their colleagues are impaired. In another intervention, mental health practitioners might help veterinary practices to set up regular mental health screenings of workers (i.e., for burnout, anxiety, or suicidal ideation) to help identify issues in their initial stages. Early detection and treatment are key. In this prevention level, mental health practitioners might provide support to veterinary professionals who were caught using or accessing drugs. Working with individuals at this stage is meant to “catch” the potential problem and prevent it from getting worse.

Mental health professionals can also provide mental health consultation services to help veterinarians develop and establish thorough clinic practice standards. These standards should include steps to obtain due process for individuals who may be impaired. In the case of a veterinarian experiencing opioid dependence, secondary prevention might include providing consultation to the veterinarian and staff to set up a modified work schedule so the veterinarian can return to their job without risk of accessing drugs. In addition to supporting veterinary professionals experiencing mental health or substance use issues, we need to keep in mind the colleagues who may be caught off guard when a veterinary professional seeks or is encouraged to seek help for drug use. Therefore, the services provided to veterinary staff may include counseling to those working with an impaired professional, including grief counseling.


Tertiary Prevention Interventions

Tertiary interventions are necessary when veterinary professionals relapse or have a drug addiction and need rehabilitation and ongoing support. This stage of prevention is meant to keep the situation from getting worse. Again, this stage requires the mental health professional to pull on actions from the previous two stages, ensuring the veterinary professional is safe, connecting them to resources in their community, and assisting them to develop a healthy support network. To further support the tertiary prevention efforts for this group of professionals, mental health practitioners can host support groups for participants to explore their mental health concerns and share strategies for living well. If veterinarian professionals are terminated from their positions, mental health practitioners can advocate for veterinary programs to retrain workers for new jobs when they have recovered as much as possible.

For mental health professionals to provide services to this specialized group, we need to understand that veterinarians and veterinary professionals face unique pressures. Not only are their workloads excessive and their hours long, but they also must face anxious and emotional clients and animals, often having to make life-or-death decisions about unwanted or sick animals. These stressors, along with other practice-related factors, contribute to the veterinary profession’s challenges of burnout and compassion fatigue, which are associated with mental health and substance use disorders, as well as suicide-related behavior.

Case Discussion

Melinda reluctantly came to counseling at her primary care doctor’s urging. Her mother had convinced her she needed help dealing with being overwhelmed, stressed, isolated, and anxious. She told Melinda to speak to the doctor about getting her anti-anxiety medication adjusted, given her stress and lack of sleep. Melinda has been on a low dose of an SSRI since graduating with her bachelor’s degree. She visited her doctor, explained what was going on, and he increased her medication. The doctor also asked her if she wanted something to help her sleep. Melinda became quiet and reluctantly admitted that she had borrowed some medication from the veterinary hospital where she worked to help with sleeping. It was at this time that her doctor told her she needed to seek help.

Melinda learned that the company she worked for offered financial support for those seeking counseling, but she was afraid of what people would say if they knew she needed help. Throughout her years in veterinary practice, she knew that people generally thought veterinarians played with puppies and kittens all day and did not think anyone outside of the profession would understand. She tried to forego counseling and try to resolve the issues herself but realized she wasn't managing well. In the past, Melinda would go to the gym five days a week to help manage her anxiety and stress. She noted that going to the gym always worked for her, but now she didn’t have time to do that. She also indicated that she was having trouble sleeping. All Melinda wanted to do when she got home from work was sleep. Sometimes she was too tired to cook and would pick up fast food on the drive home. Everyone at work thought Melinda was okay but tired due to long hours.

As a young adult, after working diligently to obtain her undergraduate degree and working at a local animal shelter, Melinda had finally been accepted to a veterinary school after three years of submitting applications. Her new friendships at school and enthusiasm for her career helped her manage the program's mental demands. She was concerned about additional student loans but did not consider the future impact of high-interest rates accruing during and after school. The program's high demands and extensive studying prevented any students from getting jobs during school to offset some of these costs. Melinda did her best to live within her means and focused on completing her degree.

Once she graduated, Melinda was selected for a 1-year rotating specialty internship and was excited for the opportunity to improve her clinical skills. Although internships have a low salary despite their highly demanding schedules and on-call hours, Melinda felt the experience would be important when looking for a full-time position. She deferred student loan payments and, upon completing her internship, obtained a small animal general practice position with a five days per week schedule. Melinda was excited about being out of school and moving forward in her career.

When student loan payments came due, Melinda began making payments. She was disheartened to see the amount of interest her loans had accrued but felt empowered to have her dream career and start planning her future. Due to the high cost of living where she lived and her debt-consciousness, she shared a two-bedroom apartment with a roommate.

Melinda noted that she worked 55-60 hours per week on paper, but she stayed late at work after every shift catching up on phone calls and writing medical records. Since generating revenue was a high priority in this practice, she picked up additional shifts and was now averaging 60–70-hour work weeks. She felt relieved as she saw the larger paychecks and ignored her exhaustion, telling herself it would pay off in the long run. Feeling pressure from both clients and hospital management, Melinda frequently agreed to squeeze in additional cases during the day, and it was not uncommon to skip lunch. She indicated that she was losing weight but didn't have time to eat. She was increasingly tired but saw opportunities to pick up additional shifts as a good opportunity to help pay off the student loans. She often didn't have enough energy to get to the gym at night, a key stress reliever during college and veterinary school, so she would periodically “find a medication” from the clinic to help her energy level.

Melinda was having trouble sleeping and would wake up thinking about cases. She would replay patient exams and lab results in her mind, worrying if she had missed something. Melinda noticed some cases where she had forgotten to finish typing a medical record, and clients were calling asking for lab results more frequently because she didn't have time to call them with results. When arriving at work, Melinda would often have numerous lab reports to review, refill requests to fulfill, and client calls to return about sick pets. She struggled to find time to get everything done. It was relatively easy to take medications from the clinic without being noticed, and she had been doing so for the last six months before seeking counseling. She began periodically taking a stimulant medication from the clinic to help her boost her energy and then a sedative to help her sleep at night.

Melinda reminisced about the first few years of her career, when she had mentorship, and wished she could go back to those days. She felt increasingly alone both at work and in her social life. When she wasn't in surgery, a large part of her day was spent seeing sick pets, trying to work within owners’ budgets for diagnostics and appropriate treatments without sacrificing quality of care, end of life consultations, and client education for wellness and preventative care. Relationships at work were good, but all the team members were under stress. Some long-term patients had recently been euthanized, which was adding to everyone's emotional strain.

Melinda said she had begun reducing shifts and trying to minimize the extra caseload but started to feel guilty when saying no to additional “fit ins” throughout the day. A client recently posted a review on Yelp berating her for being unable to fit a pet in on the same afternoon the owner called. Another screamed at her on the phone for wanting to charge for the laboratory testing to help figure out the cause of a pet's weight loss and accused her of not caring about animals. She was also worried about a tough case requiring many follow-up visits. The owner had started to have financial concerns, and Melinda was worried that without the continued follow-up to regulate the pet's disease, the pet might start to decline.

Continued negativity from clients, the pressure to meet revenue goals set by the practice, self-care reduction, lack of personal space at home, worry about cases, and financial concerns drove Melinda to wonder if she made the right career choice. Given the high debt and interest rate on her student loan payments, she felt trapped in her current position, since a change for a lesser salary would make it impossible to make loan payments. After five years, she still had never taken time to travel, which had been something she had been hoping to do once she had a stable job. She realized she was not meeting her goals of meeting someone and starting a family. Melinda spoke to her manager and tried to reduce her hours down to four days a week; she then worried about the pay cut's impact on her finances. Melinda used some vacation days but felt she was not able to get her mind off work. She began to realize there wasn't much that she enjoyed in life anymore.

Primary Prevention: If we had been able to work with Melinda while she was still in her training program or as a new professional, primary prevention approaches would have focused on preventing or reducing the chances of acquiring a substance use disorder and/or mental health disorder. Prevention strategies at this level would likely include psychoeducation and skills development focused on awareness of the effects and potential consequences of SUDs and the importance of attending to wellness and mental health (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors). Given the stigma of seeking therapy Melinda seems to hold, we would work to destigmatize seeking mental health therapy, framing it as a source of support and one way to promote self-care, much like her time at the gym. We would make sure to provide connections to community and profession-specific resources that support veterinarians, such as state wellbeing programs for veterinary professionals. Considering the immense stress associated with student loans, having resource information about debt management training on hand would be another important prevention strategy to assist Melinda.

Secondary Prevention: Melinda is experiencing stress from work, the burden of a sizable student loan, and guilt (and possibly shame) for taking medication not prescribed to her from her place of work. From the perspective of secondary prevention, the focus is on harm reduction. Providing referrals to the resources identified in primary prevention would be appropriate in the secondary prevention process. Melinda will likely appreciate the information to help with her loans, but the referral alone is not enough to help her address her maladaptive behaviors. First, it is essential to assess for baseline severity of symptoms and coexisting mental health disorders. Given her reluctance to therapy, working with Melinda using motivational interviewing therapy might help her work through her ambivalence. Motivational therapies, such as motivational interviewing, encourage a client’s readiness for change and may help Melinda realize and voice her personal goals. To reduce harmful behaviors, for clients whose substance use is mild, CBT and social skills and other skills training (e.g., communication skills, stress management, problem-solving, and identification of the effects of the medication she’s taking without medical oversight) are reported effective. With addiction, a combination of motivational incentives/contingency management rewards and CBT appears to be an effective treatment intervention. Group counseling is especially effective in creating a support network. In addition to group counseling, there are profession-specific support networks available. One such group is Not One More Vet, which came about to prevent suicides among veterinarians. The last element of secondary prevention is to build in a relapse prevention plan into the client’s treatment plan.

Tertiary Prevention: Tertiary prevention would focus on relapse prevention and/or advanced substance abuse, the long-term effects of the abuse, and the impact of complications associated with SUDs. Relapse is common (and often part of the journey) in recovery. So, planning for relapse is an important part of any prevention plan. As a result, there are a number ways mental health practitioners can assist clients incorporate tertiary prevention approaches in their treatment. For Melinda, the following are just a few options. Focusing on relapse prevention, Melinda is encouraged to continue meeting with her therapist. However, the focus in therapy would be less on skill development and more on supporting her practice and implementation of her newly acquired (or reinforced) skills (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors) in her work setting and personal relationships. These skills are critical in her being able to deal with shifts and changes that happen in life, positive and negative. A related strategy would be to work with Melinda to identify and recognize the shifts and changes in her personal life or career that might negatively impact her sobriety and mental health and potentially open the door for relapse. Melinda’s continued involvement in her support group is also encouraged, so she can keep on learning healthy strategies from her peers.

In the case that Melinda’s substance use progresses and she opts to seek inpatient treatment, it is important for the practitioner to know of or to consult with colleagues about reputable rehabilitation programs. Helping the client research and select a rehabilitation program that best suits her needs fits in with tertiary prevention planning. Finally, should Melinda experience long-term medical or other disability effects of her substance use, she may need the support of a vocational rehabilitation counselor for assistance with employment support.

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This brief article and case study propose making connections with and offering support to veterinarians and veterinary professionals from a prevention model perspective, engaging with them in training programs during their medical training and in the community. We propose not waiting for veterinarians to enter our practice for intervention, but rather reaching out proactively and identifying opportunities for providing psychoeducation, consultation, and advocacy.


Resources for Veterinarians and Mental Health Clinicians

State Wellbeing Programs for Veterinary Professionals
Debt Management Training
Not One More Vet


References

American Veterinary Medical Association. (n.d.) State wellbeing programs for veterinary professionals. https://www.avma.org/advocacy/state-local-issues/state-wellbeing-programs-veterinary-professionals

Geller, J. (2016, June 15). Dark shadows: Drug abuse and addiction in the veterinary workplace. DVM 360 Magazine. https://www.dvm360.com/view/dark-shadows-drug-abuse-and-addiction-veterinary-workplace 

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