Chronic Embitterment and Organisational Justice

There has been a substantial increase in recent years in the incidence of stress-related sickness absence from work. In the United Kingdom during 2005–2006, an estimated 10.5 million working days were lost through stress, depression or anxiety caused or made worse by work, equivalent to an annual loss of 0.45 days for every worker [1]. The International Labour Organisation has estimated that the cost of stress amounts to over 10% of Britain’s gross national product. The burden of sickness absence due to stress is likely to be similar in other countries of the European Union, in North America, and also further afield.A major problem in interpreting such data, and in devising appropriate interventions, has been the very broad, and imprecise, definitions of stress. Stress may lead to the onset of common psychiatric disorders, notably depression and anxiety. However, work-related stress may lead to sickness absence even when no formal psychiatric diagnosis is present. Characterising circumstances when this may occur is important both in public health terms and to develop focused interventions. One well-known example of a type of work-related stress associated with sickness absence is burnout. Recently, there have been 2 papers published in Psychotherapy and Psychosomatics on post-traumatic embitterment disorder (PTED) [2,3]. It has been argued that this should be considered a new psychiatric diagnosis [2]. This article will briefly review the key features of embitterment, compare and contrast this newly reported condition with burnout and with some established psychiatric diagnoses, outline some organisational concepts likely to be relevant, and comment on the diagnostic utility of embitterment. For reasons outlined below, the condition will be described as chronic embitterment, rather than post-traumatic embitterment syndrome.Michael Linden, who first described post-traumatic embitterment, has defined it as: ‘an emotion encompassing persistent feelings of being let down, insulted or being a loser, and of being revengeful but helpless’ [2]. According to the diagnostic criteria of the syndrome, people experience embitterment in response to a single exceptional negative life event, which is regarded as the cause of the embitterment. Those experiencing embitterment report repeated intrusive memories of the critical event, and blame themselves for the event, for not having prevented it, or for not being able to cope with it [2]. Although there is considerable comorbidity between embitterment and other common psychiatric disorders, notably major depression, dysthymia and generalised anxiety disorder [3], the condition is characterised by a combination of features which do not commonly occur together in these other disorders – anger, rumination, helplessness and appraisals of injustice, all focused on the cause of the embitterment.Clinicians working in occupational health readily recognise this syndrome when it is described to them, and can easily recall people they have assessed who presented with it. This not only supports the face validity of the syndrome, but also suggests that it might be widely prevalent, as Linden has suggested [4]. Another feature of embitterment is the burden it often places on employers (see ‘Organisational perspectives’), and it may be that the syndrome is recognised so readily because those who present with it are conspicuous among patients presenting to occupational health for the time and effort they demand. Clinical observation suggests that 2 of Linden’s proposed diagnostic criteria may not be present in all cases. One criterion is that people blame themselves for the event [2]; this will be commented on later. Secondly, Linden has proposed that there is a single exceptional life event identified as precipitating the onset of the syndrome [2]. However, in some cases, rather than a single event, there appears to have been a series of adverse events, of a similar nature, which have had a cumulative effect. To include such cases within the syndrome, it is possibly more accurate to refer to the syndrome as chronic embitterment, rather than as a post-traumatic embitterment disorder. Further research is needed to clarify this.It has been proposed that PTED shows some similarities to post-traumatic stress disorder (PTSD) [2,5]. In particular, both have been described as ‘reactive disorders’, arising in response to particular stressors. However, in the case of PTSD, this has become increasingly questionable. In particular, the symptoms of PTSD can arise even in the absence of a severe life-threatening event, and can occur even in the absence of any history of such events, in people who have other psychiatric diagnoses [6]. A recent editorial has suggested that: ‘by narrowing a physician’s analysis to a single event, a PTSD diagnosis may downplay or even ignore crucial pathogenic features that are found in the broader context of a patient’s personality, developmental history, and situational context’ [7].The same is probably true of PTED. On the one hand, as Linden et al. [4] have acknowledged, there is likely to be disagreement among clinicians and others as to what constitutes a single exceptional negative life event which precipitates the onset of the illness, one of the core diagnostic criteria of PTED [2]. On the other hand, focussing predominantly on a single event as the precipitant of the embitterment disorder runs the same risk as noted above for PTSD, of playing down the individual and contextual factors also likely to be important aetiologically, as they are in PTSD [8]. Taken together, these factors again support naming this syndrome chronic embitterment, rather than post-traumatic embitterment.Consistent with this, previous studies have reported symptoms of PTSD among employees who have been bullied, although many cases failed to fulfil the complete criteria for PTSD, particularly because of the nature of the trauma [9,10,11]. With the benefit of hindsight, it is likely that these cases fit the diagnosis of chronic embitterment. Burnout is a state apparently characterised by emotional exhaustion, depersonalisation and a perceived lack of personal accomplishment [12,13]. Superficially, there appear to be considerable similarities between burnout and chronic embitterment. Both conditions commonly result from work-related stress. Although chronic embitterment can occur in the context of any human relationship that has ‘gone wrong’ [4], it appears to be most widely prevalent in work settings. Similarly, burnout is most commonly encountered among those who care for others, either professionally (such as teachers or healthcare professionals) or personally (such as families or carers). By the time embitterment is diagnosed, it is usually associated with a long period of sickness absence [4], and similarly, burnout predicts absence from work [14]. Both conditions appear to arise from a combination of contextual factors and individual characteristics or vulnerabilities. Associations have been reported between burnout and personality traits [15]. However, such associations with generic and stable personality characteristics are likely to be so non-specific as to be unhelpful, either in understanding the origins of the condition or in designing appropriate interventions. Such personality traits appear to be less important than work-related factors in the aetiology of burnout [16]. Of potentially more interest is the finding that burnout among healthcare professionals is related to ‘stress of conscience’, where those affected find themselves unable in their work to reach the high standards they believe they have a duty to meet [17]. Similarly, burnout is more common when discrepancies exist between the values of the affected individual and the organisation employing him or her [18]. These are examples of the application of the social-cognitive model of personality, which emphasises the importance of manifestations of specific aspects of personality in particular circumstances or contexts, rather than relying on stable traits [19,20]. Similarly, people who develop chronic embitterment commonly hold strong personal beliefs related to their work and their contribution to society, and violation of such strongly held personal beliefs is said to underlie chronic embitterment [4]. Further investigations, perhaps using the social-cognitive model of personality, are likely to be productive.Linden [2 ]has proposed that PTED should be considered as a new psychiatric diagnosis. Here too, the comparison with burnout is perhaps helpful. Despite a burgeoning literature, there appear to have been few if any clinicians or researchers making a robust case for burnout to be included in the standard psychiatric classifications. However, this highlights a major difference between burnout and chronic embitterment. The most commonly used screening instrument for burnout, the Maslach Burnout Inventory, was not based on clinical observation nor derived from a theoretical model, but developed statistically from an arbitrary set of items [16,21]. It is therefore perhaps not surprising that the precise nature of burnout remains unclear. Most researchers appear to agree that exhaustion is a key feature, but the status of depersonalisation and lack of accomplishment as integral components of burnout remain disputed [16,22].By contrast, the features of PTED were initially recognised by clinical observation [2,4]. Chronic embitterment is definitely seen in clinical practice. The question is: what are the similarities and differences between the features of chronic embitterment and those of common psychiatric disorders? If chronic embitterment has distinctive features, this could add further support to its claim as a new psychiatric diagnosis.The hallmark features of chronic embitterment, shown by the vast majority of those who present with the disorder, are intrusive thoughts and memories, negative mood, expressed perceptions of injustice and embitterment itself [4]. While this combination of features is not found in other psychiatric disorders, it is of interest to examine whether the properties of these individual features might also be distinctive in chronic embitterment. This applies particularly to intrusive thoughts. Linden [2] has suggested that the intrusive thoughts in PTED are similar to those found in PTSD. It is important to discriminate between flashbacks and ruminations, both of which occur in PTSD [23]. If Linden is correct that chronic embitterment is usually precipitated by a single event, then one might expect flashbacks to occur in PTED also. However, if the development of embitterment is cumulative, at least in some cases, flashbacks would be expected to be less common. It may be significant that in the basic descriptions of the embitterment disorder, there does not appear to have been any explicit reference to flashbacks specifically.Ruminations occur in a variety of psychiatric disorders, notably depression and anxiety as well as PTSD [24]. Ruminations are also commonly associated with anger [25,26]. Depression, anxiety and anger can all be associated with embitterment [3]. It is therefore of interest to consider whether ruminations occurring in embitterment have any distinctive features. One potential difference between ruminations in embitterment and those in depression or anxiety is that in the former, the focus of the ruminations appears to be on the events or circumstances giving rise to the embitterment, while in the latter, rumination may focus on the symptoms of the disorder (in other words, ‘worrying about worrying’) [24]. Linden has noted that his patients with PTED regard their ruminations in a positive way, in that they consider it important not to forget the cause(s) of their embitterment. This on its own is not unusual; some people who are depressed, anxious, or even angry, consider that rumination will benefit them [27,28]. Previous research suggests that the persistence of rumination is associated with negative mood states and with impaired problem solving [29,30]. In chronic embitterment, as in other disorders, this may contribute to the persistence of the condition.As already noted, one of the other characteristics of PTED noted by Linden (and listed as a diagnostic criterion) is that patients blame themselves for the event causing the embitterment, or for not having prevented it [2]. This is a curious observation, and certainly worthy of further investigation, because the combination of self-blame and rumination is found in depression, but chronic embitterment appears to be distinct from depression. Anecdotal evidence suggests that at least some of those who present with chronic embitterment focus their blame on others rather than on themselves – on their managers or superiors, to whom the events causing the embitterment are commonly attributed. This is consistent with anger being a predominant emotional response in embitterment, as well as with the observation that people who are embittered have an overwhelming sense of injustice, usually accompanied by frustration and even helplessness when thinking about how to resolve the situation. The constellation of features of chronic embitterment may therefore be even more distinctive than has been described to date.Chronic embitterment has behavioural manifestations that also appear distinctive from those of other psychiatric diagnoses. People who are embittered often attempt to engage others in their problems, particularly those others whom they perceive as having caused the problems, or as having potential influence over the solutions. Such attempts to engage others are not features of depression or of PTSD, and they have implications for how managers and organisations should respond to embittered employees (see ‘Organisational perspectives’). As noted above, a strong belief that one’s manager or employer has behaved unjustly or unfairly is a key belief in people who show chronic embitterment. Therefore, implicit in the experience of chronic embitterment is a perceived failure of organisational justice [31]. In the individual case, events which have contributed to the development of the chronic embitterment have outcomes that are perceived to be unjust (these are perceived failings of distributive justice). Clinical experience suggests that those who show chronic embitterment also perceive injustice or unfairness in the and which to these outcomes is and also in their own by the organisation or by their managers perceived failure of justice). evidence that of these of organisational justice can an contribution to adverse work such as and work [31]. to how these contribute to the experience of chronic embitterment at an organisational the development of appropriate and to the risk of embitterment the of the embittered the of such research would not only contribute to more of the problems, but could also the development of appropriate important organisational likely to be to chronic embitterment is the work This suggests that employees have beliefs about what they have been by the organisation for which they work, and what they are expected to contribute to the organisation in the the values and which the that the organisation There is also an of – if the or more from the organisation of have been In the more in the of from the in the is about being by the organisation and is about being it The crucial (and one likely to be to organisational is that the work is made and not to or work as has been identified in a variety of of of a strong work are readily in organisations with a strong public such as health or and those which are such as the of the the between and but in some there may be an important what the of his rather than the within a particular For a will have of her which may be of the organisation in which Such public are probably also associated with a strong although published evidence for this appears to be the work is and not a strong sense of as is likely among healthcare teachers and others, may increase the risk of a between the values and those of the While such are they are by It is to whether organisations is to the or those with strong are more likely than others to rise to chronic embitterment. In the healthcare the caused by the work may be by between and organisational values and by the of as well as clinical managers the may have of the values and of their may the importance of these values because of from their own the the to have been there is evidence that the the perceived the more impaired perceived of the work are likely in people with chronic embitterment, but research is needed to that the has in of in many the question whether being made from one’s can be a of embitterment. In this it is perhaps no that in Linden’s the case who lost his through of the of are more likely than managers to to the of its while managers more commonly to the organisation having to its due to or factors or to between and organisation embitterment is less likely to arise if an can the loss of his or her as due to rather than to to justice a for example for and a in to their case more focus of chronic embitterment appears to be on specific managers a specific if a one but in a the focus of chronic embitterment is expected to remain with the previous rather than to the new to a new in a new organisation a However, it is that people who have chronic embitterment in one organisation are more to embitterment in This remains to be by but for the time it is probably for occupational health professionals to include about embitterment in their with new Linden et al. [4] have presented evidence for the of among those with PTED. In this is defined as an – particular of understanding and with life that people with PTED are in particularly when to understanding and solving personal to However, these in can be by specific above suggests that ruminations might be an appropriate focus for interventions. appears to be in this and of a formal of in a will be of particular other of should also be support the of in anxiety and PTSD on the of rather than the of thoughts. For people with embitterment, the focus would be on their rumination, particularly on their beliefs and about to Similarly, which with is in depression and anxiety and would be expected to for those with embitterment. In and which has been to the of depression, anxiety and PTSD an important of the is to work as they In chronic embitterment, this would the cause(s) of the embitterment to the of the might also be expected to again by the embittered focus from the ruminations and the cause and of the embitterment The to which these are in the of chronic embitterment further individual are shown to be for the with chronic embitterment, it is also important that these should not from the of appropriate at an organisational and with individual For embittered commonly engage in about the cause(s) of their embitterment. It is not to an with experiencing chronic embitterment, to a of events, and an with with their those who are embittered are likely to to considerable about their circumstances and the of the embitterment. the response to this can be Those the embittered may consider that to his or her will be as being However, this to the embittered ruminations, which can in lead to of the As a people with chronic embitterment can amounts of time and effort from their organisation and from occupational health To whether this is of chronic embitterment further If it will be of interest to also the of the embittered perceived to of the embitterment – is this due to rumination or is to other For if the individual that his case is the that others do not this may be to not having presented the of the case Chronic embitterment is associated with considerable for the embittered having to time from work, and its can have substantial for others, notably the embittered employers and healthcare in that at this of research embitterment, these features that embitterment is a syndrome that has diagnostic utility It also appears that chronic embitterment a of features that are not found together in any other psychiatric diagnosis. If this is by further this will some of chronic embitterment as a psychiatric factors might possibly from there is some of symptoms between chronic embitterment and depression, anxiety and PTSD, and of these disorders are found with chronic embitterment. However, this does not chronic embitterment as a psychiatric diagnosis. In the for there has been no that diagnoses have to be from one and are The cases where the cause(s) of embitterment and the beliefs about injustice are not to the presenting with embitterment, but would be widely and by For embitterment may be due to by a manager who is widely recognised as his In such cases, there would be that the has been unjustly such it might appear to add to to then the embittered a psychiatric because this might that the problem with that rather than with his or her situation. However, this is not of depression or anxiety may arise because of work-related when it might be in an individual case that an of depression is very to have in the absence of particular events at work, it is appropriate to the as and it in the should be considered embitterment even when it could be by the cause of the embitterment being considered to be a and to burnout, the features with chronic embitterment that research might focus on the relationship lack of a between they of a common set of work-related some people develop chronic embitterment, while others experience are there differences in the conditions giving rise to In this similarities in the circumstances giving rise to these it is that people with chronic embitterment find the and to their cause with of the emotional exhaustion of burnout. absence from work through is a major public health reasons for this, and devising appropriate interventions, is therefore of considerable Such and are likely to work organisations as well as affected because work-related stress usually from between and their work on chronic embitterment is in its but evidence suggests that this condition is certainly worthy of further not only as a potentially important cause of sickness but also for its on the individual and the of the particular features associated with chronic embitterment a Further research is to the condition more in particular, to how the key features of chronic embitterment to one the in which these are from those found in other psychiatric and how these develop over time and are For if rumination the development of the embitterment syndrome has been reported in PTSD this will have substantial implications for work with individual and could also the employers with at an organisational In further research will contribute not only to appropriate interventions, but would also support for chronic embitterment as a psychiatric features of chronic embitterment, notably anger and rumination, have been associated with of adverse outcomes of its chronic and intrusive nature, embitterment is very likely to contribute to an important in While to the of to stress, to the the for being to to adverse or in this the to to the chronic adverse of embitterment and its is that the of chronic stress on is by perceived stress As noted above, a key feature of chronic embitterment is the of injustice at work, and of the of that such perceived injustice the of are likely to their work as and such is associated with Similarly, because the embitterment is intrusive and over the life work, from work is likely to be and this has also been associated with and even with risk of from evidence is – of the studies outlined have focused on chronic embitterment However, considered these the potential for as well as for clinical of further understanding of the characteristics and of chronic embitterment, and of to patients have contributed to understanding of chronic for they have also for the and of and for with particularly The no of