Grit and Grace
Sometimes when you open your door to a knock, the thing you find on the other side changes everything. That happened to me in my senior year at college. A handful of girls from the Bible study I taught stood there looking conspiratorial. They shoved a thick envelope into my hand and hurried off, giddy and giggling. Stuffed inside I found a wad of bills along with a note, urging me to use them to attend a summer internship. To this day I do not know how my study mates knew I had wanted to attend this program devoted to following Christ in poor, urban contexts. And so I went. That summer in Boston proved to be a genuine turning point. My eyes were opened to the depth of God’s heart for those on the margins. It was the beginning of a new journey that, over time, led me to become a clinical psychologist worshipping and working with children and families in poor, urban contexts.
Like others who have opened their door to the Spirit’s knock, the years following have been filled with rewards and sacrifices, confirmations of the call and temptations to get off track, continuity and unexpected turns in the road. I joined, and was joined by, others along the way. Over 20 years later, some have left this path and gone in another direction. Some have breezed far ahead of me. Others limp but continue, resolutely. All these years after answering that first knock I find myself asking how it is that some remain on the road and wonder how we can finish the course strong. How can we, as Paul describes in Hebrews 12 “lay aside every weight, and the sin which clings so closely, and run with endurance the race that is set before (us)”…? How will those of us already on the journey help prepare those just starting? And what can we learn from those farther along?
Our presentation at the CCHF conference in Nashville this spring sought to explore some of these questions. We offered some relevant research from the professional literatures, and shared some of the stories of a few faithful individuals who have been providing healthcare in poor contexts for at least 10 years. We include some highlights from that talk here.
A Life of Paradox
We began with three observations, paradoxical in nature, that seem important to grasp in any attempt to persevere in this call. First, it seems that a life of providing healthcare among the poor:
- is unavoidably stressful, at that same time that it is uplifting and rewarding;
- involves sacrifice and dying to self on the part of those who serve, even as it can deeply nourish our spirits and yield the rich fruit of a flourishing life.
- requires strenuous, sustained and wholehearted human exertion but it can only be lived through divine grace and utter dependence upon God.
What are some of the stresses that providers of healthcare currently encounter? Recent studies have identified a large and diverse range of work-related hazards including, but not restricted to the following: excessively high patient to caregiver ratios, multiple time pressures and demands, problems without solutions, limited access to social professional support systems, inadequate resources and support personnel, need to manage the business aspects of practice, an increasingly stressful and restrictive healthcare context (including government policies, regulations, intrusions and interference from third parties, threats of serious injury from violent patients or interest groups, increased malpractice litigation and insurance costs, and an overall pressure to practice defensive medicine), and erosion of the doctor-patient relationship. 1
Healthcare providers serving in poor contexts might reasonably be expected to experience these stressors and more. Unfortunately, that means exposures to these stressors will put providers at risk for burnout. Burnout has been linked to a variety of negative personal impacts such as loss of job satisfaction and depression, as well as decreased professional capacity and effectiveness, which can lead to suboptimal patient care. 2
We asked attendees to consider for a moment what the experience of burnout is like. Conceptualized as involving the following three elements, burnout is a multidimensional experience that includes:
- emotional exhaustion (the feelings of being emotionally overextended and exhausted by one’s work),
- depersonalization (unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction), and
- diminished feelings of personal accomplishment (feelings of competence and successful achievement in one’s work decreases). 3
Rates of Physician Burnout
The American Medical Association recently (2009) published the following sobering analysis — a review of studies published in JAMA between 1984 and 2001 measuring burnout in healthcare providers generated the following rates:
- Between 46 and 80% of physicians experience high emotional exhaustion,
- 22-93% experience moderately high depersonalization, and
- 16-79% report low-moderate personal achievement.
Similar percentages were found in residents, academics, and personnel in the Veterans Administration systems.
Risk Factors for Physician Burnout
Specific factors that increase providers’ risk for burnout are not fully understood, but a number have been identified, including:
- age of provider
- lack of role clarity
- perceived inadequacy of resources,
- self-reported workload, and
- low spousal support during training.
One of the most robust findings of this literature is that younger physicians appear to be more susceptible than those later in their careers. Authors have sought to elucidate this phenomenon using developmental and cohort-based explanations. From a life cycle perspective, seasoned practitioners may have developed coping strategies over time that early career providers have not yet acquired. These strategies might include evolving more realistic role expectations, developing healthy self-protection strategies, and experiencing confidence that comes through experience. Vocational and personal rewards that might be accrued over time by more seasoned providers, such as greater work control, less workhome interference, and more home support, may also help prevent burnout. Historical and real differences in cohorts, however, may also act as contributors. Changes in the nature of practice itself, in the expectations of trainees, along with subsequent lags in the response to these changes by training institutions, may contribute to inadequate preparation, and problematic expectations for job satisfaction or support by new physicians than in previous cohorts.
Avoiding Burnout—Going the Distance
Perspectives on life, work, the prevention of burnout, and the promotion of longevity and success can take several forms, emphasizing qualities within the person, pitting work and the rest of life against each other, or viewing the two domains more synergistically.
Individual Qualities. Exemplary within a person-centered view is the psychological construct “grit”. Grit has been defined as a combination of perseverance and passion in the service of very longterm goals. 4 It entails strenuous work, persistent motivation and effort over the years, despite challenges, failure, adversity, and plateaus in progress. Stamina and sustained commitment, even in the absence of positive feedback, is at the heart of this trait. 5 What is interesting for our discussion, and what has drawn the interest of researchers over many decades, is the contribution grit plays in the successful achievement of long-term goals, over and above things like talent and IQ. Physicians, psychologists, and other professionals have already persisted through years of rigorous, demanding preparation for their professions. Successful completion of such training may mean that a person is well fitted to the demanding life of delivering healthcare in difficult contexts. But it could also leave the new professional depleted and hungry for fewer demands, an end to delayed gratification, and more rest, comfort, control, and material rewards. Students, early career professionals, and veterans alike may benefit from an honest self-assessment of our past, present, and future experience and capacity for sustaining persistence and passion over time. The literature on grit reminds us to take a view over the decades, rather than over the years.
Work vs. Life. Work vs. life perspectives on avoiding burnout pit the demands of one domain against the other. Since time and energy are limited, resources allotted to one arena are seen as unavailable for the other. In response, physicians and others whose work involves service are often admonished to strike a “balance” between work and the other parts of their lives. The image of the scale conveys this well; work is on one side, life on the other, and we are to aim for equitable apportionment. For some, the idea of working toward balance in our lives is a helpful notion. But for others with multiple role obligations and shifting conditions in their personal and professional or ministry lives, the goal of achieving a static state of equilibrium can sound burdensome, unattainable, and frankly, unrealistic.
Along a similar vein, scholars, clinicians, and trainers interested in the wellbeing of practitioners often recommend self-care as an approach to preventing burnout. In other words, physicians and other helpers are admonished to care for themselves even as they care for others. In a search of the medical literature, we found a wide array of specific selfcare strategies being recommended that we have grouped into six categories: physical (sleep, exercise, nutrition, etc.) personal (hobbies, non-professional growth, etc.), psychological (fostering self-awareness, clarifying and prioritizing values and goals, regulating thoughts and feelings, etc.), professional (scheduling of work and regular time off, practice arrangements and delegation, ongoing professional development, etc.), social (protecting time for and investing in relationships with family and friends), spiritual (religious practices and spiritual exploration), and institutional (policies and procedures impacting experience of work). 6 In the broader literature on self-care, there is evidence that regular and flexible use of a variety of strategies benefits helpers personally and professionally. 7
Work and Life. In contrast to characterizations of life and work as antagonists are those that view work as enhancing the rest of life. Studies generated within the emerging psychology-of-working perspective highlight the contributions work makes to essential human needs for survival, relatedness and self-determination. 8 In this literature, working emerges as essential to the wellbeing of both individuals and communities, even as it can be a context for struggle and stress.
Christians wanting to understand the relationship of their calling to provide healthcare to the poor and their own wellbeing, however, will want to examine Scripture for wisdom regarding these questions. We shared one compelling passage in Scripture that seems rich, provocative, and relevant to this discussion. Every year in one of my graduate courses, I (Canning) share this passage, from the 58th chapter of Isaiah. It contains an astounding compilation of blessings for the people of God, namely that: their light will break forth like the dawn, their healing will spring up speedily, righteousness will go before them, the glory of the Lord will be their rear guard, the Lord will answer when they call and say “here I am” when they cry out, their light will rise in darkness, their gloom will be as noonday, the Lord will guide them continually and satisfy their desire in scorched places, make their bones strong, they will be like a watered garden whose springs do not fail, their ancient ruins will be rebuilt, they will raise up the foundations of many generations, they will be called the repairer of the breach, the restorer of streets to dwell in, they will take delight in the Lord, be made to ride on the heights of the earth, and be fed with the heritage of Jacob (taken from verses 8-14).
After reading the list of blessings I ask my students “how many of you want these in your life?” The response is unanimous and resounding — we long for them. We would treasure having any one of the promises. The thought of experiencing them all together takes the breath away. Turning back to the passage, I read the students another list. This one contains God’s instructions to the Israelites that He says will lead to the blessings. It includes: loose the bonds of wickedness, undo the straps of the yoke, let the oppressed go free, break every yoke, share your bread with the hungry, bring the homeless poor into your house, cover the naked when you see him, do not hide yourself from your own flesh, pour yourself out for the hungry, satisfy the desire of the afflicted, turn back from seeking their own pleasures on the Sabbath and honor it (taken from verses 6-7, 10 & 13). The juxtaposition is a surprise. The human flourishing described in the first list is tied, paradoxically, to doing justice, pouring out our lives for the satisfaction of those who are in need and afflicted, living as if they are our own flesh — not exactly the recipe put forth in the “balance” and “self-care” models. While a thorough exploration of this complex relationship was far beyond the scope of our presentation, we wanted to put a spotlight on the link presented in this Scripture: one in which we spend ourselves for the satisfaction of those who are poor and oppressed, and in doing so, we ourselves are satisfied.
Training and Faithfulness
So where does that leave us? If “balance” and “self-care” are inadequate or in some ways misdirected objectives for the Christian living out the gospel among the poor, to what images can we turn? Again, this question requires a much more thorough treatment than we were able to provide (perhaps human flourishing can be a future conference theme?). We offered two from Scripture: training and fidelity, or faithfulness.
Training for a race, an image found in a number of Scriptures (Phillippians 3:12-16, Hebrews 12, 1 Corinthians 9:24-27, 2 Timothy 4:6-8), is a useful corrective for many conceptualizations of why caregivers ought to engage in self-care. Training for a marathon requires commitment to an arduous schedule of running to be sure. Nutrition, rest, and mental preparedness, however, are just as much a part of the training as the running itself. Neglect these aspects and the running will suffer. Overdue the running, and you will never make it to race day. Adopting a “training mindset” means orienting your life around a focused goal. From this perspective making time for rest, for example, does not take away from the goal of winning the race, but supports it. A training mindset also entails living in a way that acknowledges the multiple dimensions of the person: physical, social, and psychological, as well as spiritual.
To consider faithfulness, we turned to the work of Steven Garber. In 1996, Garber interviewed former students of Christian colleges who had continued on to live vibrant lives for Christ. 9 From these interviews, done 25 years after graduation, Garber gleaned three distinguishing characteristics:
- Mindset: a Christian worldview that was realistic and coherent. They held convictions of truth that were strong enough to meet the challenges of relativism amidst a culture of secularization and pluralization.
- Mentors: role models whose lives embodied this worldview. They built relationships with these people who could inspire and guide them in their pursuit of faithfulness.
- Community: a social context in which to develop and live out their convictions. This community continued to challenge and strengthen them providing both accountability and affirmation.
The findings from Garber’s study offer valuable guidance for those pursuing faithfulness and flourishing as we provide healthcare for the poor. Without question, how we think matters. Integrating our Christian worldview with every aspect of our lives impacts how we perceive, and persevere through, stressful and challenging situations. Grit, as described above, may be an important component of this mindset. Furthermore, the redemptive story of our faith enables us to re-conceptualize the brokenness and pain that surrounds and is within us and those we serve. We are liberated to hope in the midst of situations that seem hopeless, as we trust in the faithfulness of He who empowers our own faithfulness.
This mindset cannot be maintained in isolation. Garber’s work reminds us that relationships and community are necessities if we are to flourish. We must invest enough in relationships and community that can be sources of mutual support — an often difficult prospect for those whose lives are spent caring for and serving others. While relationships and community must be, to some extent, local, the Christian Community Health Fellowship network seeks to bring people together with this similar mindset and mission, providing a source of professional, spiritual support across the continuum of training, start-up and long-term flourishing in service.
People of Grit and Grace
We ended our presentation with some lessons learned from the stories of some “gritty and graced” folks who have been helping to deliver healthcare in poor communities for 10 years or more. Based on interviews with four very different staff members at the Lawndale Christian Health Center, we shared challenges and rewards they have found in their work, along with some strategies and ways of thinking that appear to support their longevity and vitality. We honor them (Noe Formosa, Bruce Miller, Tirsa Pfeil, & Bruce Rowell) and the God who called and sustains them and all of us who are doing and will do the work. We end here with a prayer for blessing that we offered to those in attendance and extend to those reading this now: may God continue to supply all that you need to carry out the calling He has given you; may you flourish and be satisfied as you pour out your life for Him in order to satisfy those He loves. Your life and ministries attest to the fact that God has not forgotten those devalued in our society. May you be deeply assured that He will certainly not forget you.
1 “Stress in physicians, a deadly dilemma,” Newsletter of the American Institute of Stress 10 (October 2007).
2 S.S. Chopra, W.M. Sotile, M. O. Sotile, “Physician burnout,” Journal of the American Medical Association 291, no. 5 (2009) : 633.
3 C. Maslach, “Burnout: A multidimensional perspective” in Professional burnout: Recent developments in theory and research. Eds. W. B. Schaufeli, C. Maslach, T. Marek (Philadelphia: Taylor & Francis, 1993), 19-32.
4 A.L. Duckworth, C. Peterson, M.D. Matthews, D.R. Kelly, “Grit: Perseverance and passion for long-term goals,” Journal of Personality and Social Psychology 92, no. 6 (2007) : 1087-1101.
6 see Jensen, Trollope-Kumar, Waters & Everson, 2008 for one example of this literature. P.M. Jensen, K. Trollope Kumar, H. Waters, J. Everson “Building Physician Resilience,” Canadian Family Physician 54 (2008) 722-729.
7 J.C. Norcross, J.D. Guy, Leaving it at the Office: A Guide to Psychotherapist Self-care (New York: Guilford, 2007).
8 D.L. Bluestein, “The Role of Work in Psychological Health and Well-being,” American Psychologist 63, no. 4 (2008) 228-240.
9 Steven Garber, The Fabric of Faithfulness (Downers Grove, IL: InterVarsity, 1996).
Sally Schwer Canning, Ph.D., Psychologist/Behavioral Health Consultant, Lawndale Christian Health Center, Associate Professor of Psychology, Wheaton College, Wheaton, IL.