Research initiatives addressing rising suicide rates among veterinarians

virginia techBreathing noisily, a 14-year-old dog stood in the corner of an examination room at the Virginia-Maryland College of Veterinary Medicine’s Veterinary Teaching Hospital.

The dog’s owner, motionless in a chair against the wall, wept openly. Crouched before her, a resident looked directly into her eyes. “You’ve made the right decision,” he said gently. A veterinary student standing by the examination table lowered his head in agreement.

At that moment, the dog approached and licked his owner’s hand. The resident rose and backed away to give them space. The owner rested her forehead on the dog’s head and caressed his sides. A few quiet minutes passed.

Then, with great care, the resident led the dog out of the room, followed by the student.

In human medicine, when a patient is facing death, a chaplain might be brought in and a social worker called to guide the grieving, bewildered family. Likewise, pet owners facing health care decisions for their beloved companions need direction, compassion, and support — as do the caregivers themselves.

In veterinary medicine, ever-intensifying stress and compassion fatigue among practitioners handling case after case have begun to take a heightened toll on clinicians and vet students alike. Within this climate of hard work, suffering and pain, fatigue and despair, veterinary wellness burst into the public consciousness and became an issue of national significance, especially at teaching hospitals.

“Increasing rates of suicides, depression and compassion fatigue, and decreasing personal and professional satisfaction among veterinarians emphasize the importance of creating a wellness culture within veterinary professional programs,” said Jacque Pelzer, director of admissions and student services at the veterinary college.

Responding proactively to a growing body of research and a culturally evolving willingness to acknowledge the need to care for one’s physical and mental health issues, Virginia Tech’s veterinary college has followed in footsteps laid by successful programs at the University of Tennessee, Knoxville — which established the country’s first program in 2002 — North Carolina State University, and The Ohio State University: A veterinary social work program is available to support not only pet owners considering treatment options and navigating end-of-life care for their pets, but also clinicians, caregivers, and students who daily encounter health crises and profound grief.

Critical care

A licensed clinical social worker who treated students from all walks of life at Virginia Tech’s Cook Counseling Center for the past five years, Trish Haak has moved seamlessly onto the Veterinary Teaching Hospital (VTH) health care team to facilitate communication and well-being among the hospital’s clinicians, staff, students, and clients.

“Three years ago, I started working with Trent Davis’ yellow Lab, Moose, providing animal-assisted therapy,” Haak said, explaining how her clinical focus shifted. “I identified clients whom I thought would benefit from Moose’s presence, and it was truly remarkable how his presence would break down barriers in the sessions. Through my work with Trent and his growing animal-assisted therapy program, I was inspired to pursue veterinary social work.”

Her interest fully piqued, Haak discovered the Veterinary Social Work Program at the University of Tennessee and has gone on to pursue an extensive post-graduate certificate that requires coursework in compassion fatigue, animal-assisted therapy, bereavement and grief, and the link between human and animal violence, along with a keystone project, hands-on workshops, conferences, and an international summit.

As her first order of business at the VTH, Haak is establishing a comprehensive veterinary social work program to address wellness issues at the college, providing support, crisis intervention, and grief education; hosting wellness workshops that serve the college’s staff, students, and clients; and leading a biweekly animal loss support group that meets in the Hahn Horticulture Garden on campus.

She plans, as well, to introduce animal-assisted therapy at VTH, having already begun working with Virginia Corrigan, an assistant professor of community practice in the college’s Department of Small Animal Clinical Sciences. Aligning well with Haak’s program, Corrigan’s research interests span such areas as the human-animal bond and veterinarian-client communications.

Available five days a week, Haak maintains regular office hours at the VTH, and with her open-door policy, anyone can consult with her as the need arises.

“Because this is a new role, I have visited each of the hospital’s services to acclimate myself,” Haak said. “Now, I am spending some time discovering the best ways for that particular service to refer clients. Every clinician has his or her own preferences, and each service works a little bit differently.”

In order to best assist hospital clients, Haak is also working with the services to land upon the most-viable methods to determine which clients may benefit from her support. Even in her first few months in the position, clients have been referred by VTH clinicians who are already familiar with veterinary social work programs.

“So far, most clients have come to me from emergency situations,” Haak said. “I suspect that emergency services and oncology, given their roles in health care, will continue to be the largest referral source for clients who might need extra support.”

Going forward, Haak’s plan is to “get out there, build awareness of this resource, and offer support every day.” She explained that the VTH’s veterinary technicians have been particularly helpful in her onboarding: “They’re the boots on the ground to gauge client needs. I think that the more they see me, the more they’ll understand the services I offer.”

Haak is equally dedicated to announcing her availability to support the hospital’s caregivers. “I’ve been talking one-on-one with people to explain how I can be of help,” she said. “Although I’m not here for ongoing counseling or therapy, I am here to help mitigate compassion fatigue and provide support in whatever capacity will assist people in their day-to-day work.”

Sometimes, Haak explained, an outside perspective is exactly what’s needed; however, if more support is called for, she is able to share resources that are available locally. In many respects, she is an adjunct to Virginia Tech’s Employee Assistance Program, which is a vital part of the university’s health care benefit program. “I can refer to an EAP provider here,” she said, “or I can provide a similar consultation and referral service depending on the need.”

In an effort to further enhance the benefits and better assure the success of the VTH program, Haak also has been in conversations with social worker Neely Conner, practice manager of Carilion Clinic’s EAP. Conner has expressed a deep interest in veterinary social work and believes that Carilion’s wellness approach is transferable to the program at the veterinary college. “We’ve been talking about how we can align our programs more closely and work together to address compassion fatigue,” Haak said.

Because veterinarians often juggle busy schedules and multiple roles, the timing of such a collaboration couldn’t be better, in Haak’s estimation. “Social work support services have been in hospitals for a long, long time, but veterinarians have been doing it all on their own,” she said. “Now, people are becoming aware of the many hats that veterinarians are wearing.”

Contributing to veterinarians’ compassion fatigue, Haak explained, can be the long hours, the more-intense cases, the ethical burdens and moral stress surrounding euthanasia, and the attention directed to owners responsible for their pet’s care.

“I see veterinarians wearing this counselor hat because they’re very empathetic,” she said. “So, I do understand the benefits of my role as another team member, if the program can be modeled that way: to absorb some of that human-to-human aspect of the veterinarian’s responsibilities.”

Fulfilling precisely that role is crucial to the well-being of the veterinary profession, according to Janice Neumann, a health and wellness writer in Chicago. In her story, “Need to make tough decisions about your pet? A veterinary social worker can help” in a mid-September edition of The Washington Post, Neumann explained that veterinary social workers are essential because of the “changing relationship between humans and their animal companions. … Many people treat their pets like children and expect them to be treated accordingly by veterinarians.”

It stands to follow, then, that in the face of clients’ high expectations, veterinary social workers can ease some of the burden experienced by caregivers, as well as support owners who are shouldering the stress and anxiety of their pet’s illness.

As the program continues to evolve, Haak is regularly in the company of students, residents, and interns during rounds, focusing on communication and wellness. Her role allows her to contribute to discussions about difficult cases and to help young practitioners establish boundaries and interact appropriately with each other and with clients who are having trouble understanding their pet’s treatment.

Not unexpectedly, the services that Haak has introduced at the veterinary college have been embraced as both necessary and timely.

“Care of animals depends upon the physical and mental well-being of our clients, students, staff, and clinicians,” said VTH director Terry Swecker. “As a mental health professional, Trish has strengthened our efforts in such critical areas as grief counseling, dealing with compassion fatigue, assessing and promoting work-life balance, and, in general, destigmatizing mental health challenges. Trish is a valuable asset, and we are very fortunate to have her on our team.”

Pelzer agrees: “Having a social worker in the clinical setting will help with cultivating student’s emotional and social health. Additionally, our social worker will increase student awareness about wellness and resiliency. We hope to produce veterinarians who are more self-aware and better able to engage in their personal and professional lives.”

A veterinary state of mind

In light of the wide-ranging demands of their work, veterinarians are squarely at risk to experience intense stress, a dangerous situation that, borne out by recent research, has attracted much-deserved attention, followed by an array of restorative mental health resources aimed at reversing the tide.

Five years ago, the Centers for Disease Control and Prevention released the results of the first-ever mental health survey of U.S. veterinarians, which was conducted by researchers with the National Association of State Public Health Veterinarians, Auburn University, and the CDC.

According to an article in the Journal of the American Veterinary Medical Association, respondents were “more likely to suffer from psychiatric disorders, experience bouts of depression, and have suicidal thoughts compared with the U.S. adult population.” In addition, the data suggested that “nearly one in 10 U.S. veterinarians might experience serious psychological distress, and more than one in six might have contemplated suicide since graduation.”

In early September, another study published in JAVMA, “Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014,” revealed that male and female veterinarians, in comparison to the general population, were 1.6 times more likely and 2.4 times more likely, respectively, to complete suicide.

In response to such disturbing findings, efforts are already in place at Virginia Tech to both assess mental health needs and forge solutions to ensure the well-being of the campus community.

In fall 2018, the Virginia Tech Mental Health Task Force, appointed by Executive Vice President and Provost Cyril Clarke — the former dean of the veterinary college from 2013 to 2017 — was charged with studying mental health resources on campus and devising initiatives and strategies for their implementation in order to improve services and promote mental health. Led by Chris Wise, assistant vice president for student affairs, the task force released its recommendations this past March.

A member of the task force, Laura Hungerford, a professor of veterinary health and epidemiology and the head of the veterinary college’s Department of Population Health Sciences since 2016, now shares leadership of the newly formed Mental Health Initiatives at Virginia Tech with Executive Director Christopher Flynn, who has served as the director of the Cook Counseling Center since 2006.

While Flynn will lead the campus-wide implementation, Hungerford will join him in convening working groups of students, faculty, and staff to address the task force’s recommendations, which are related to mental health awareness across the university, mental health education and prevention, ongoing support for and intervention with students, and effects of policies and procedures on student functioning.

Most significantly, the task force noted a dramatic increase in the demand for mental health services on campus: The number of Tech students receiving counseling increased by 43 percent in the past five years.

On the heels of this finding and the task force’s recommendations, immediate changes that were instituted include the addition of more counselors at the Cook Counseling Center, provisions for annual tracking of students’ mental health to allow for comparisons nationally, the planned hiring of a director of financial wellness in Hokie Wellness, and increased efforts to identify and engage trained aides and mental health advocates in student groups.

Well-being at Vet Med

Not only did the task force’s report laud steps taken by the veterinary college to reduce students’ grade anxiety by way of a change to its grading system, the college has several initiatives in place to support student well-being, raise awareness of mental health issues, and connect the veterinary community with mental health resources.

Before they even begin classes, incoming veterinary students receive QPR (“question, persuade, refer”) training during orientation. Often compared to CPR in its speed and urgency, QPR teaches students how to identify suicidal people and guide them to the resources they need.

Along with free counseling services at the Cook Counseling Center, Virginia Tech’s Psychological Services Center, a behavioral and mental health training clinic for the university’s clinical psychology Ph.D. program, offers low-cost mental health services to all students.

With extremely busy and frequently changing schedules, veterinary students often find it difficult to make time to visit the counseling center, especially when they’re in clinical rounds. Both to encourage their participation and to simplify the process, Cook counselors and their therapy dogs are embedded in the college during the five-day work week, ensuring that their services are readily accessible.

This fall, counselor Trent Davis and therapy dog Moose, named the Virginia Veterinary Medical Association’s Animal Hero in 2019, have been joined by counselor Sarah Dunleavy and therapy dog Wagner. Both teams provide on-site animal-assisted therapy to veterinary students: Davis and Moose are in the building on Mondays, Wednesdays, and Fridays, while Dunleavy and Wagner can be seen on Tuesdays and Thursdays.

It should come as no surprise that Dunleavy has noticed that the college’s aspiring veterinarians respond particularly well to animal-assisted therapy.

Beyond their love of animals, the veterinary community also benefits from the “physiological and emotional reaction that happens when you connect with an animal,” she explained. Interacting with Wagner can release oxytocin, as well as lower blood pressure and anxiety levels.

Because of his calming abilities, Dunleavy has used Wagner to help students with trauma and also during exposure therapy. “I know grounding techniques, and they’re helpful, but Wagner can do it in a fraction of the time that it takes me,” Dunleavy said. “It may take me 15 minutes. It takes Wagner about 15 seconds.”

Therapy dogs like Wagner also help reduce stigma while raising awareness of mental health services. When the counselors walk the dogs through the building, students are more likely to stop and chat, allowing the counselors to build rapport and spread awareness of available resources. Perhaps as important, the dogs also thoroughly normalize the counselors’ presence in the school.

Even with counselors — and therapy dogs — in their midst, many veterinarians and veterinary students are nonetheless hesitant to seek assistance when they’re experiencing mental health issues.

Proactive protection

Aligned with the pervasive idea that asking for help is a sign of weakness, the fear of exposing their vulnerability keeps many from reaching out or expressing their distress, a conundrum that deepens a potentially dangerous situation. Such reticence obviously obscures others’ ability to discern that someone is struggling, which in turn makes interventions more difficult.

In an effort to counteract these sorts of situations and help those who may be suffering, the veterinary college has partnered with Jody Russon, assistant professor in the Department of Human Development and Family Science in the College of Liberal Arts and Human Sciences.

“Veterinarians are more than two times as likely to die by suicide than the general public,” said Russon, a suicidologist who focuses on factors that contribute to suicide and on prevention and intervention practices that should be deployed to address suicidality. The daughter of two veterinarians, Russon points out that a range of realities potentially contributes to this unpleasant statistic, the most significant of which may be that veterinary medicine is the only profession that euthanizes its patients.

As the principal investigator on a research project, “Addressing Suicidality among Veterinary Students,” funded by a seed grant from the Advancing Transdisciplinary Communities in Rural Health Research initiative at Virginia Tech, Russon set out to determine how to best implement a suicide and mental health screening tool into the context of the veterinary college as a means to mitigate suicide. “The whole goal of this study,” she said, “was to determine if a suicide screening tool would be feasible and acceptable and to identify what barriers might prevent putting such a tool into place, one that could catch suicide ideation early and then allow triage in an effective way.”

Self-identifying as a “community-engaged researcher” who “cannot be an outsider,” Russon enlisted three co-investigators based at the veterinary college: Terry Swecker, VTH director; Jenni Zambriski, assistant professor of epidemiology in the Department of Population Health Sciences; and Kathy Hosig, associate professor in the Department of Population Health Sciences, director of the Virginia Tech Center of Public Health Practice and Research, and Virginia Cooperative Extension public health specialist and State Program Leader for Health.

“The first thing we did was engage a transdisciplinary advisory board that included organized veterinary medicine, practicing veterinarians, research veterinarians, and public health specialists to help us design the way we would conduct this research and design the actual questions in order to receive more responses,” Russon said.

The ensuing step involved preliminary research, interviews, and focus groups with students, house officers, staff, practicing veterinarians, and administrators to explore wellness and health needs as expressed by the veterinary college community.

Using mixed methods, several quantitative questions were asked first, for example, “What is your comfortability asking about suicide? If you were struggling, would you seek help?” These questions were followed by several qualitative questions: “Talk about the stressors at the veterinary college. If there were a screening tool put into place, would you like that?”

Russon noted that the results returned multiple themes, including the frequent mention of programming already in place at the college, such as wellness courses, yoga, and stress-management activities. “Across veterinary medicine in general, and specifically at the veterinary college,” she explained, “there has been a recurring focus on addressing stress and addressing nutrition, but nothing fully focused on mental health, suicide, and direct prevention strategies.”

Just as Russon had anticipated, an even stronger theme surfaced, one that could be considered a barrier to implementing a screening process.

“Because no one is immune to the stigma of mental illness, one of the core themes we detected in our qualitative interviews was this concept of mental toughness,” Russon said. “If we show vulnerability, our struggles, we may be perceived as being too weak or not having the grit to succeed in this intense profession. Or, we would perceive ourselves as not having the grit to deal with this difficult profession.”

Beyond potentially undermining the successful deployment of a screening tool, this prevailing attitude may already destabilize the effectiveness of the college’s use of QPR training with incoming students. “Students put on a front,” Russon said. “They save face, which undermines the identification of their struggles.”

In response to this deep-seated culture of mental toughness, Russon’s most significant recommendation is that screening should be conducted by the veterinary college’s social worker and kept confidential. She also advised that faculty and staff be called upon to collectively normalize the screening tool among students in an effort to offset the stigma. “Although we cannot force everyone to complete the screening tool,” she said, “we can create a culture in which it is acceptable to complete this wellness screening.”

Along with the strong themes that surfaced, Russon was pleased that the majority of the interviewees revealed positive perceptions. “Students, faculty, staff, and administrators were overwhelmingly excited about and accepting towards this kind of intervention and screening tool,” she said. Put plainly, most respondents said that the tool was important and a good idea.

Having presented these preliminary results to the veterinary college in early November, Russon said that the next course of action is to secure funding to implement the screening tool at the college. “The tool under consideration is very comprehensive,” she said. “It asks about nutrition, sleep, depression, anxiety, suicidality, relationships, safety behaviors, access to means, and a variety of different considerations.”

Following the tool’s implementation and testing, the research team will then determine if the tool promotes help-seeking behavior or reduces the amount of mental health distress during the course of the year. If successful, the tool will be expanded and disseminated to other veterinary colleges that may be interested.

“Suicidality often occurs later in one’s veterinary career,” Russon said, “so the idea is that early intervention is essential. If we teach people that it is acceptable to struggle and receive help, that they can be helped in an effective and confidential way, then maybe different strategies will be used later in life.”

         
 

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