The Challenge of Burnout: An Ethical Perspective
Michael W. Hayes, EdD, LPC, NCC, BCP,
This article reviews the literature of professional burnout since the inception of the term by Freudenberger (1974). The term burnout is defined and contrasted with other terms in the literature such as compassion fatigue and vicarious trauma. Included in the article is an exploration of burnout across the helping professions and how and if the multiple etiologies generalize to other related professions. The article is framed as self-care being an affirmative duty for the practitioner that is defined in the ethical codes of multiple disciplines. The article concludes with a discussion of strategies for the practitioner to explore that represent evidence-based treatments in the literature.
Keywords: Burnout, Compassion Fatigue, Freudenberger, Self-Care
- Define professional burnout as it is presented in the literature and summarize the research developments since the initial identification of the occurrence of professional burnout.
- Describe the symptoms from the literature that indicate the onset of professional burnout.
- Explain strategies that represent ethical, evidence-based practice in the remediation and prevention of professional burnout.
Originally published in American Association of Integrative Medicine Journal, February, 2015.
The Challenge of Burnout: An Ethical Perspective
The Codes of Ethics of the major professional organizations representing psychotherapists address self-care in the provision of therapeutic services. An important focus of provider self-care is in the prevention, recognition, and remediation of impairment among practitioners. A brief review of the history in the literature introduces a discussion of current terminology that represents modern challenges to the provider in the ever-present quest for proactive self-care. Additionally, a review of evidence based interventions along with practical strategies for the prevention and remediation are included to assist the practitioner in this area of ethical compliance.
The discussion in this article will focus on professional burnout and the accompanying symptoms in the literature. A distinction will be made in terms of defining provider burnout, compassion fatigue and vicarious trauma. There is considerable overlap and some disagreement on the definitions of the aforementioned conditions because symptoms often generalize from one to another (Baird & Kracen, 2006). One of the main purposes of this article is to bring clarity and consensus to these specific challenges that providers face in an effort to better recognize, prevent, and remediate their occurrence.
The origin of the term burnout is credited to Freudenberger (1974), and this development has generated a great deal of research. It is noted, however, that much of the research in the area of burnout has been conducted without the guidance of a theory (Maslach & Jackson, 1984; Maslach, & Jackson, 1986). Shaufeli and Enzman (1998), as cited by Jawaher, Stone, and Kisamore (2007), suggest that burnout is a work related indicator of one’s psychological health. The presence of cynicism, indifference, uncaring attitudes, and reduced personal accomplishments are also indicators of severe burnout (Maslach, 1982). These definitions are consistent with those of the developers of a three-tier model of burnout, which lists stress arousal and energy conservation prior to the onset of exhaustion (Girdin, Everly, & Dusek, 1996). According to Kesler (1990), Edelwich and Brodsky (1980) have described a four-stage model of burnout, marked by an enthusiastic phase, where the counselors make themselves overly available to clients. This is followed by stagnation, marked by a return to normal expectations along with levels of discontent. Thirdly, the period of frustration is manifested by withdrawal, boredom, and less empathy. Finally, there is the fourth phase described as apathy, which is described as the embodiment of burnout (Kesler).
The terms secondary trauma, vicarious trauma, and compassion fatigue are sometimes used by lay populations interchangeably, the assumption being that they represent a single observation of diminished productivity. For the purpose of clarification, the following brief definitions underscore the differences between secondary trauma, vicarious trauma, and compassion fatigue with generally accepted definitions of burnout. Secondary trauma is a term that should be used when a set of psychological symptoms are present that mimic the symptoms of post-traumatic stress disorder. Vicarious trauma occurs when a professional experiences trauma due to exposure to the graphic trauma experienced by a client (Baird & Kracen, 2006). Compassion fatigue occurs after exposure to repeated crises, and can emerge suddenly without warning. The symptoms of compassion fatigue may include confusion, exhaustion, and lack of motivation. There exists a level of overlap in symptoms involving compassion fatigue and simple burnout. Additionally, the symptoms may not be indicative of the real cause of the onset of compassion fatigue. The recovery is typically rapid with appropriate treatment (Figley, 1995). According to Dubi and Marcus (2006) in a literature review by Collins and Long (2003), definitions were further crystallized with the authors’ statement, “a synthesis of these descriptions demonstrates that the term compassion fatigue can be used interchangeably with the term secondary traumatic stress” (p. 421). Additionally, Figley (2002) describes compassion fatigue as a type of caregiver burnout, yet differing in terms of etiology, diagnosis, and treatment from a case of simple burnout.
Christina Maslach has emerged a researcher of note in the area of professional burnout during this timeframe, especially in the area of burnout in the mental health professions. During her early work, Maslach described burnout as a loss of regard for those the mental health practitioner was serving. This loss of concern was manifested by a loss of empathy and positive regard for the client. Maslach also suggested that clients of a certain type or diagnosis could be related to the occurrence of burnout symptoms. Her work also included the concern of heavier caseloads as possible triggers for burnout symptoms (Maslach, 1978). What is perhaps still regarded as one of the most often utilized instruments in the measurement of burnout was developed by Maslach and Jackson (1984). The Maslach Burnout Inventory (MBI) contains four different subscales for the measurement of emotional exhaustion, depersonalization, personal accomplishment, and personal involvement (Maslach & Jackson, 1984).
The seriousness of burnout becomes a reality with a simple investigation into the costs associated with afflicted employees. The economic costs are apparent in increased employee absenteeism, which is to be expected with the symptoms of burnout reported in the literature. This could include headaches, insomnia, chronic fatigue, and gastrointestinal disturbance. Additional yet equally draining conditions include depression, hypertension, and substance abuse as a result of attempts to self-medicate. Some employees will eventually leave their place of employment as a result of severe burnout symptoms, sometimes leaving the employer with significant losses associated with training, compensation, and benefits. In terms of simple economics, it becomes clear that addressing burnout is in the employer’s best interest as a fiscally responsible approach, in addition to the need to address the issue in human terms (Maslach & Leiter, 1997).
Cherniss (1980) viewed burnout among members of the helping professions as a time when a formerly engaged worker becomes disengaged with their work as a result of the stressors associated with their job assignment. He further described burnout as a three-step process, beginning with a stage where the worker detects a discrepancy between the demands and resources of the job. The emergence of emotional strain, including fatigue and anxiety, characterizes the second stage of this model. Finally, the third stage sees the worker attaining a point of coping defensively at work, where true burnout is occurring and the effectiveness of the worker is significantly decreased or stopped (Herr & Cramer, 1988).
As with all matters in the counseling profession, burnout must also be considered within the context of a multicultural phenomenon. One such example is the association between social supports and burnout and how those support systems vary in terms of significance and availability with culture. Pines, Ben-Ari, Utasi, and Larson (2002) investigated this area in a study involving students from Hungary, Israel, and the United States. In short, the literature suggests that in most cases, the presence of social supports acts as a buffer to the onset of burnout symptoms, yet in some studies there has been little or no supporting evidence of this claim. In either case, the issue of culture must be considered as it relates to the support availability and significance.
Repetitious and mundane tasks, along with the lack of opportunities for advancement, have been identified as workplace issues associated with burnout. Such tasks have grown significantly as counselors have attempted to more closely align their services with those of the employing institution. This has served as an attempt to establish their services as more critical to the mission statement of the employer, as well as becoming indisposable to the school management hierarchy (Fortney, Wallace-Schutzman, & Wiggins, 1982). In a separate study in the field of education, teachers identified the presence of ambiguity in job expectations as well as role conflict as being responsible for the onset of burnout (Herr & Cramer, 1988). Similar to the Maslach (1978) article regarding burnout as it relates to caseloads, researchers have associated elevated incidents of burnout, with high caseloads among those with personal challenges (Farber & Heifetz, 1981).
There is a body of literature from this same timeframe where investigators have associated burnout symptoms with life events. Pines, Aronson, and Kafry (1981) associated positive and negative life events with the presence or lack of presence of burnout symptoms, while Sarason and Johnson (1979) associated burnout with job satisfaction. In terms of gender and burnout, there is evidence suggesting that there are differences in responses to stressors on the basis of gender (Tung, 1980). As the majority of school counselors are women, the issue of gender warrants further exploration on the topic of professional role challenges and burnout (Bryant & Constantine, 2006).
Another body of research from this period focuses on the relationship of stress and stress reactions in the workplace with the level of placement in the organization (Axelrod & Gavin, 1980). Additionally, evidence was emerging at this time that identified stressors from the workplace and outside the workplace, suggesting that both must be active for significant burnout symptoms to occur (Pardine, Higgins, Szeglin, Beress, Kravitz, & Fotis, 1981). A connecting thread in these bodies of research concerning stress is that there is a gap that divides expectations and reality. Most agree that burnout occurs as a result of a continued phenomenon and not due to a single event (Herr & Cramer, 1988). This distinction is at the hub of the differences in definitions of burnout, secondary trauma, vicarious trauma, and compassion fatigue.
The literature suggests that there are significant implications for supervision in the area of counselor burnout. There is some specific evidence that counselor burnout may be related to a poor administrative structure. Murphy and Pardeck (1986), as cited by Bernard and Goodyear (2004), suggest that extremes in supervision style may actually foster symptoms of burnout, with the added evidence that burnout may be more associated with organizational structure than within the individual practitioner. The evidence does suggest that the presence of supervisor structure is associated with reduced burnout symptoms, especially when that structured approach to supervision is an environment that encourages two-way communication and constructive feedback. Additionally, it is of great benefit to organize the work environment so that regrouping, networking, and consultation time is built in as a means of counselor growth. Finally, it is recommended in the literature that the issue of supervisor burnout be considered in the construction of a work environment (Bernard & Goodyear). The issue of school counselor burnout is further complicated in that formal, clinical supervision is seldom available as a non-evaluative system of support. Administrative supervision, which is connected with employee evaluations, tends to be the sole form of supervision in school counseling. Other than the initial practicum and internship phases of graduate level training, the school counselor is at a distinct disadvantage in accessing clinical supervision opportunities, especially as compared to their professional counseling colleagues in non-school settings.
Kesler (1990) cites Schneider (1984), where the regular addition of unreasonable demands may end up producing such overt physiological symptoms as heart attacks, cancer, or even suicide. Further concerns with regard to the question of role and its relationship to burnout include the issue of being pulled in many different directions and having responsibilities being continuously added to already over-taxed schedules. While Kesler indicates that burnout symptoms are established over time, it is also reasonable to expect that interventions for addressing those symptoms, while worthwhile and appropriate, will facilitate the desired changes in comparable periods of time. As many burnout symptoms are physical in nature Kesler cites Casteel and Matthews (1984) in their work on sensory issues. Their model suggests that the cumulative nature of stress and its impact on burnout indicates that relaxation training such as neuromuscular massage could be an effective component of self-care. This raises the question of self-care with counselors, which is a topic of interest among both professional counselors and counselor educators. A comprehensive self-care approach for the school counselor has both supervisory and ethical considerations. Teaching self-care concepts and practices in counselor education programs appears to be universally accepted, yet the results in the literature are less than encouraging (Roach & Young, 2007). Figley (2002) has suggested that therapists working in settings where there is a significant level of chronic illness tend to neglect their own self-care.
An area of encouragement in the prevention of burnout in recent years lies in the developing area of mindfulness integration into training models as a self-care initiative. Burnout, vicarious trauma and compassion fatigue have all been indicated in the literature as areas that can be targeted prophylactically in programs utilizing mindfulness strategies in provider training. Much of the focus on mindfulness in health care in recent years has been attributed to Jon Kabat-Zinn, who has advocated for the use of meditation, yoga, and body-scans in generating self-awareness for providers applying strategies using Mindfulness-Based Stress Reduction (MBSR). Additionally, Shapiro, Brown, and Biegel (2007) have done a quantitative study of counselors and psychotherapists in training which demonstrated a significant decrease in stress and negative affect when mindfulness strategies were incorporated into their training (Christopher and Maris, 2010).
Finally, the personal attributes of the counselor are identified as a predictor in burnout (Wilkerson & Bellini, 2006). The implications extend from admission procedures in counseling programs to appropriate self-study and staff development initiatives that address the relationship between attributes and burnout. Personal attributes, along with role challenges and institutional factors should continue as areas of focus on the assessment, treatment, and prevention of burnout with school counselors. The responsibility for prevention and treatment is complex in that it is a supervisory concern of the employer as well as a professional responsibility of the individual counselor. As in all factors concerning professional practice, the focus of the above strategies is on a better served client where the practitioner practices their craft in an unimpaired state.
Developing Provider Strategies for Addressing Burnout
Given the evidence in the professional history, the practitioner can construct personal strategies for both the prevention and remediation of burnout symptoms. The symptoms of burnout in the literature often parallel those symptoms present in various types of depression. One of the first considerations for the practitioner that determines that such symptoms are present is to obtain an expedited physical examination by their primary care physician. An honest and forthcoming discussion with the primary care physician regarding the symptoms of concern will be very helpful in possibly obtaining a medical rule out as the etiology in question. Besides the physical examination, the therapist should also look at lifestyle, including nutrition and exercise activities. Besides a sound nutritional program and regular exercise, the therapist should also be looking at other areas of balance in their lives. This could include spiritual development, family activities, and the positive use of recreational time. Assuming that the medical and lifestyle issues have been appropriately and successfully addressed, the next step is for the therapist to investigate the specific job where the symptoms are presenting. The issues that are specific to the position could be addressed with a review of responsibilities and caseload that can be discussed with the administration. If the issues that are presenting the greatest challenge to the therapist cannot be resolved with the administration, the therapist should begin to investigate alternative employment opportunities.
Professional counseling occurs in a variety of settings with a variety of population groups. This is a great benefit to the counselor struggling with burnout issues as sometimes a change in setting or populations can be therapeutic regarding the presentation of burnout symptoms. Another approach that is supported in the literature is to engage into a revised program of professional development. This could be anywhere from a revised focus of Continuing Education Unit participation, an area of specialization or certification, or even a new degree program (Cottone & Tarvydas, 2003).
It is also the responsibility of the counselor to initiate appropriate strategies for the prevention and remediation of such impairment. This would include, if indicated, the possibility of entering into professional counseling (Welfel, 2006). There is the additional consideration that communities vary significantly in terms of resources that are available from which the school counselor may refer. It is also suggested in the literature that all counselors will experience some level of burnout. Welfel (2006) has suggested that as many as 1 to 5% of practicing counselors may exhibit evidence of full syndrome burnout, while as many as one third may demonstrate evidence of emotional exhaustion. It should, however, be noted that not all stressors are negative; therefore, the counselor must be able to ascertain and monitor the negative from the benign in the course of professional practice. The establishment of a comprehensive self-care approach as a vital component of professional practice is indicated in the literature, and these strategies should include continuing professional growth, the regular practice of consultation and supervision, professional networking, and stress management initiatives (Cottone & Tarvydas, 2003). These strategies should be an ongoing process, rather than a response to the appearance of symptoms. Remley and Herlihy (2007) suggest that burnout is not a condition, but instead represents a process leading to impairment. Being cognizant of this process and employing continuous strategies for prevention and remediation are indicated as ethical behavior for a school counselor. The American Counseling Association Code of Ethics does provide direction to the counselor who may be reaching impaired status (ACA, 2004).
The multiple etiologies and onset of professional burnout have generated significant amounts of literature since the term was established as a professional challenge. The proactive therapist should be self-aware and orchestrate a balanced professional and personal life along with developing a meaningful plan for professional development for the prevention of burnout. Likewise, the ethical therapist must recognize the symptoms of burnout and put appropriate interventions in place as an ethical responsibility. The implications for practitioners are explicit in that burnout must be recognized as a challenge to professional practice with appropriate prevention strategies and responses in place as both a practical and ethical matter.
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About the Author
George Harris PhD
I am the consulting psychologist for the Kansas City Regional Office for developmental disabilities. I also provide consulting for Midwest Career Center, an evaluation program for Ministers. I taught Psychology course for Johnson County Community College and Avila College while in graduate school. I provide pre-employment evaluation and fitness for duty services to several areal police and fire departments. .
Published by Dr. Robert O' Block in The American Assocaition of Integrative Medicine Journal February 2015.