Research roundup: Burnout in mental health providers

Professional burnout in mental health practitioners and strategies for managing and preventing burnout.

Burnout commonly affects individuals involved in the direct care of others, including mental health practitioners. Burnout consists of three components: emotional exhaustion, depersonalization of clients and feelings of ineffectiveness or lack of personal accomplishment (Maslach, Jackson & Lieter, 1997). Emotional exhaustion may include feeling overextended, being unable to feel compassion for clients and feeling unable to meet workplace demands. Depersonalization is the process by which providers distance themselves from clients to prevent emotional fatigue. Finally, feelings of ineffectiveness and lack of personal accomplishment occur when practitioners feel a negative sense of personal and/or career worth.

Studies estimate that anywhere between 21 percent and 61 percent of mental health practitioners experience signs of burnout (Morse et al., 2012). Burnout has been associated with workplace climate, caseload size and severity of client symptoms (Acker, 2011; Craig & Sprang, 2010; Thompson et al., 2014). In contrast, studies examining burnout prevention have found that smaller caseloads, less paperwork and more flexibility at work are associated with lower rates of burnout (Lent & Schwartz, 2012). Burnout results in negative outcomes for both practitioners and their clients. Symptoms of burnout are not solely psychological; burnout has also been linked to physical ailments such as headaches and gastrointestinal problems (Kim et al., 2011).

The following studies examine correlates and predictors of burnout in mental health care providers. The first study investigates burnout amongst practitioners working on posttraumatic stress disorder clinical teams in Veterans Affairs (VA) health care settings. The second study examines correlates of burnout in sexual minority practitioners, and the third study investigates the impact of personality on burnout. Finally, the fourth study examines factors that may prevent burnout.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice. Psychologists looking for resources about burnout and self-care can refer to the Board of Professional Affairs’ Advisory Committee on Colleague Assistance. Resources include information about professional health and well-being and tips for self-care.

Garcia, H.A., McGeary, C.A., Finely, E.P., McGeary, D.D., Ketchum, N.S., & Peterson, A.L. (2016). The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder speciality programmes. Psychology and Psychotherapy: Theory, Research and Practice, 89, 66-81.

Treatments in Veterans Health Administration PTSD Clinical Teams (PCT), such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), expose providers to graphic traumatic material. However, little is known about the impact of this traumatic material on PCT providers. This study examined the relationship between trauma content, patient characteristics and provider burnout. The investigators also explored whether different types of trauma differentially impacted providers.

Data was collected from 137 full-time providers in a VA PCT clinic providing either PE or CPT. Approximately 60 percent of providers were clinicians with a doctoral degree in clinical or counseling psychology; the other participants were clinical social workers. Participants completed a comprehensive survey identifying characteristics of their patient population and the content of the trauma they treat. Patient characteristics included frequency of anger, personality disorders or traits and malingering. Providers also responded to questions about several workplace characteristics, such as clinical workload and co-worker support. Burnout was assessed using the Maslach Burnout Inventory.

The sample reported wide exposure to different traumatic experiences and high levels of burnout. Approximately 50 percent of the sample reported high exhaustion and high levels of cynicism. However, only 12 percent reported low professional efficacy. More than 75 percent of providers reported they felt that emotional exhaustion impacted quality of care provided to their clients. Perceptions of control over work and presence of personality disorders or traits among clients were the strongest predictors of professional efficacy. Exhaustion was predicted by concerns about having more clinical work than can be accomplished and perceptions of control over work. Cynicism was predicted by patient malingering. Although respondents reported being bothered by exposure to trauma content, trauma content did not predict burnout. The researchers suggested that the treatments offered by PCT staff may have a similar impact on providers as they do on clients, in that providers habituate to the traumatic memories. Further research is needed to understand factors that may help to prevent burnout in PCT providers.

Viehl, C., Dispenza, F., McCullough, R., & Guvensel, K. (2017). Burnout among sexual minority mental health practitioners: Investigating correlates and predictors. Psychology of Sexual Orientation and Gender Diversity, 4, 354-361.

Previous research reported that sexual minority mental health practitioners report higher rates of burnout compared to heterosexual practitioners (Viehl & Dispenza, 2015). Several factors could contribute to burnout in this population, including managing the stigma of sexual minority identity and stressors associated with gender role expectations. Furthermore, sexual minority practitioners may encounter workplace discrimination as a result of their sexual orientation. In this study, practitioner age, perceptions of reasonable workload, workplace heterosexism, workplace support and identity concealment were investigated as potential factors leading to burnout. The researchers also hypothesized that workplace support would mediate the relationship between workplace heterosexism, identity concealment and burnout. 

The data in this study came from a larger data set that included both sexual minority and heterosexual mental health practitioners. Participants were recruited online and were eligible to participate if they were mental health practitioners currently providing professional services on a consistent basis. The final sample of 84 participants included practitioners with degrees in mental health counseling, counseling psychology, clinical psychology and social work, among others. Burnout was measured using the Counselor Burnout Inventory.

No significant differences were found on burnout as a function of gender, race or ethnicity, degree type, licensure or work setting. Burnout was associated with workplace heterosexism and identity concealment, and negatively correlated with perceptions of workload reasonability and workplace support. Practitioner age was not a significant predictor of burnout. Perceptions of workplace support did not mediate the relationship between identity concealment and burnout symptoms. In contrast, perceptions of workplace support influenced the manner in which workplace heterosexism affected burnout. Specifically, higher instances of workplace heterosexism were related to increased rates of exhaustion, depersonalization and feelings of ineffectiveness among sexual minority mental health practitioners. However, the addition of workplace support to the regression resulted in workplace heterosexist experiences no longer predicting burnout. The researchers suggested that in the presence of workplace heterosexism, reduced workplace support could increase burnout levels. However, the inverse may also be true: increased perceptions of workplace support may help reduce burnout levels. Clinicians and supervisors should note the importance of workplace support and its relation to burnout.

Somoray, K., Shakespeare-Finch, J., & Armstrong, D. (2017). The impact of personality and workplace belongingness on mental health workers’ professional quality of life. Australian Psychologist, 52, 52-61.

This study explored constructs related to burnout, including professional quality of life, compassion satisfaction and secondary trauma. Professional quality of life encompasses the positive and negative mental health outcomes that individuals may experience in their role as a helper. Secondary traumatic stress (STS) may occur when exposed to someone else’s trauma. The combination of STS and burnout has been referred to as “compassion fatigue.” In contrast, positive outcomes for mental health practitioners, such as a sense of achievement and joy in their jobs, are known as compassion satisfaction. This study sought to provide a more well-rounded picture of mental health workers’ well-being by examining compassion satisfaction, burnout and STS concurrently. Additionally, workplace belongingness and practitioner personality traits were investigated as predictors of professional quality of life.

The sample consisted of 156 mental health workers employed in an Australian nongovernment organization providing counselling services to a range of clients. Practitioners were psychologists, counselors, mediators and social workers. Participants answered questions regarding demographics, work roles, history of trauma (both personal and work-related) and sense of workplace belongingness. The Psychological Sense of Organisational Membership scale measured the sense of being liked, respected, valued and needed in the workplace. Personality was measured using the NEO Five-Factor Inventory. Finally, the Professional Quality of Life Scale was used to measure compassion satisfaction, STS and burnout.

Participants reported feeling high levels of belongingness within their workplace and high levels of compassion satisfaction. This sample reported low levels of burnout and STS, which were strongly positively correlated. Compassion satisfaction was associated with extraversion, openness, agreeableness and conscientiousness, and negatively correlated with neuroticism. Furthermore, compassion satisfaction had a strong positive correlation with workplace belongingness. Both burnout and STS strongly positively correlated with neuroticism.

Additionally, the researchers examined regression models predicting burnout, STS and compassion satisfaction. Age and conscientiousness significantly predicted compassion satisfaction, with older participants reporting more compassion satisfaction. STS was significantly predicted by neuroticism and personal trauma experiences. Finally, burnout was significantly predicted by low workplace belongingness, younger age, neuroticism and low agreeableness. This research demonstrated that mental health workers experience satisfaction in their jobs despite being exposed to work-related stress and trauma.

Jergensen, K. (2017). Practice what you preach: An exploration of DBT therapists personal skill utilization in burnout prevention. Clinical Social Work Journal. DOI:10.1007/s10615-017-0633-6.

Previous research suggests that more severe client symptomology can increase the risk of developing burnout.  This suggests that Dialectical Behavior Therapy (DBT) therapists could be at higher risk; however, research indicates DBT therapists experience lower levels of stress and burnout. DBT includes a component of therapist self-care built into the program (the consultation team) that could explain lower rates of burnout. The goal of the current study was to assess how other components of the DBT model, such as the specific skills used with clients, may assist DBT therapists in their own stress management. DBT Skills are grouped into four categories: mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. The researchers asked to what extent DBT therapists personally utilize the DBT skills in their own lives for stress reduction, stress management and burnout prevention.

Eligible participants were mental health therapists currently practicing in the field as DBT practitioners, including providing individual DBT, DBT skills groups, or both. A convenience sample was utilized, and participants were not asked to identify their educational background or degree. A total of 135 practitioners completed questions assessing stress level and use of DBT skills in daily life. Burnout was assessed using the Bergen Burnout Indicator-Modified scale.

Participants worked with a variety of client populations, including borderline personality disorder, chemical dependency and bipolar disorder. Daily personal use of mindfulness and emotion regulation skills were endorsed at a higher frequency than other categories. All the mindfulness skills as well as skills such as Problem Solving, Self-Soothe and Radical Acceptance were used in daily life by at least 75 percent of participants. Practitioners reported that mindfulness techniques were the most helpful, and interpersonal effectiveness techniques the least helpful, in reducing stress in daily life. Total skills use increased as age increased, and results indicated that the longer a person spends practicing DBT the higher the frequency in which they personally utilize DBT skills. Finally, DBT skills use was significant predictor of decreased burnout. However, burnout in general was relatively low within the sample surveyed, suggesting the need for further investigation of the relationship between DBT skills use and burnout. Specifically, the researcher suggested that the generalizability of benefits of DBT skills should be explored among non-DBT practitioners.

Clinical implications

These studies indicate that burnout is a problem faced by many clinical providers. Burnout results from a variety of complex factors including a sense of workplace belongingness, workload, client characteristics and provider’s personal characteristics. Overall, these studies highlight the importance of preventing burnout.

Preventing burnout is a complex process that includes addressing emotional exhaustion and depersonalization of clients and attention to maintaining a sense of personal accomplishment (Rupert et al., 2015). Providers may address burnout by using cognitive strategies for managing work demands. For example, Somoray et al. (2017) encourage individuals to use problem-based coping skills and seek social support to manage stress. Jergensen (2017) suggests that DBT skills, particularly mindfulness, could be used by non-DBT practitioners to decrease risk of burnout. While self-care is important, there are also changes at the administrative level that could prevent burnout. Viehl et al. (2017) highlight the importance of workplace support, and Somoray et al. (2017) suggest that feeling valued at work may facilitate satisfaction with ones’ work. Supervisors and organizations should work to cultivate a sense of workplace support and belongingness, while also providing training and resources for self-care and strategies for coping with stress.