Identifying and Tackling Burnout

Kim Fitzgerald

PhD Psychology (Health, Rehab, and Occupational)M.Ed. Vocational Rehabilitation Counselling

Consulting Psychologist: Coaching, Return to Work, Job Analysis, Disability Management Consultancy, CounsellingReg. Psychol., Ps.S.I., CPsychol, CBDMA, DMS, BFA

The Working Dead?

Trends in entertainment industry reflect social problems: “Zombie films typically critique humanity in times of crisis. Half an hour of the Walking Dead shows enough angst and inter-group frustrations you’ll start to consider going solo during an apocalypse...”https://cccspeaks.wordpress.com/2013/07/05/lets-talk-zombies/

In the news...Half of Irish Staff on Verge of Burnout (Business World, 2015)

Physician Burnout: It Just Keeps Getting Worse (Medscape Family Medicine, 2015)

Majority on brink of stress: Office tensions rising but flexible working provides a solution (Regus Global, 2015)

Social workers are resigning from their jobs at a rate of one a week (RTE, 2015)

EU study blames long shifts for nurse burnout (Irish Examiner, 2015)

According to the American Institute of Stress, "workplace stress costs more than $300 billion each year in health care, missed work and stress-reduction." 

Identifying

Risk Factors for Burnout Syndrome

Negative Job Characteristics• Workload: Overwork and heavy

workload, boredom• Work conflicts• Diminished resources• Lack of input or feedback• Job insecurity• Effort-reward imbalance• Length of training and delayed

gratificationOccupational factors• Step hierarchy• Understaffing• High demands for employees• Number of years in current profession

and total number of years

Organisational Factors• Continuing rapid organisational

changesDemographic variables• Younger adults• Unmarried people/women caring for

childrenPersonality traits• Low hardiness• Poor self-esteemJob attitudes• Unrealistically high expectations• Financial issues (salary)

Source: Burnout for Experts: Prevention in the Context of Living and Working (2013)

Risky Roles: Emotional Labour

The Helping Professions“Cost of caring" for others in emotional and physical pain (Figley,1982).

Medical Profession:• Oncologists• Surgeons• Anaesthesiologists• Intensive care unit staff• Neonatal intensive care• Academic medicine chairs• Rehabilitation practitioners• Medicine residents and

medicine students

• Emergency service personnel

• Dentists• Nurses• Social workers• Mental health workers• Psychologists• Occupational therapists• Speech and language

therapists

Risky Roles: Emotional Labour

Source: Burnout for Experts: Prevention in the Context of Living and Working (2013)

Pressures to:PerformShow resultsBe seen as a good leader/role modelBe strong

High Level Peak Performers and/or Senior Staff:

“It’s Lonely at the Top....”

Who can you trust?Who can you talk to?

What does it look like?Employee might experience:

● Difficulty coming to work and getting started once at work

● More irritable and less patient with co-workers, clients, customers

● Lack of energy to be consistently productive at work

● Self harm: Tendency to self-medicate with alcohol or drugs, behavioural (risky behaviours)

● Becoming cynical, sarcastic, critical at work

Management might observe:● Aggressiveness and Irritability● Poor Memory / Mental

Confusion● Lower Quality of Work● Change in Working Hours● Fatigue● Bad Time Management● Mood Swings● Fearful● Loss of Self-Confidence● Loss of Motivation● Increased Absenteeism

(Calling in Sick)

Risk Factors• Personality factors: The people most likely to burn out

quickly are over-achievers, perfectionists, and pessimists

• An imbalance between work and home life: If one or the other is taking over an employee’s life, work will suffer and burnout will ensue

• Work-related stress: An overwhelming workload, increased job demands without commensurate benefits, a lack of recognition or feedback, and a loss of faith in leadership can all contribute to burnout

• Lack of involvement with decision making

Assessing

What was it before?

International Classification of Disease (ICD-10)

“Burnout: State of vital exhaustion.”

Category Z73, under: “Problems

related to life management and

difficulty”

Overlapping Symptoms: What’s really going on? It isn’t ‘burnout’ but it could be...Depression

• Trouble concentrating• Trouble remembering • Trouble making decisions• Impairment of

performance at work• Sleep problems• Loss of interest in work• Withdrawal from family,

friends, co-workers• Feeling pessimistic,

hopeless• Feeling slowed down• Fatigue

Anxiety• Feeling apprehensive and

tense• Difficulty managing daily tasks• Difficulty concentrating

Other Problems Related to the Social Environment

Not mental disorders but circumstances that may impact diagnosis, course, prognosis and treatment:

• Phase of Life• Problem Related to Living Alone• Acculturation Difficulty• Social Exclusion or Rejection• Target of (Perceived) Adverse

Discrimination or Persecution

Reference: Other Conditions that May be a Focus of Clinical Attention, DSM-V Codes, p. 724

Problems Related to Other Psychosocial, Personal, and Environmental Circumstances

• Religious or Spiritual Problems• Problems Related to Unwanted Pregnancy• Problems Related to Multiparity• Discord with Social Service Provider,

Including Probation Officer, Case Manager, or Social Services Worker

• Victim of Terrorism or Torture• Exposure to Disaster, War, or Other

Hostilities• Other Problem Related to Psychosocial

Circumstances• Unspecified Problem Related to Unspecified

Psychosocial Circumstances

Reference: Other Conditions that May be a Focus of Clinical Attention, DSM-V Codes, p. 725

Popular Assessment Tools

Maslach Burnout Inventory (MBI): 22-25 items, 3 scales: • Emotional Exhaustion (9 items)• Depersonalisation (5 items)• Personal Accomplishment (8 items)Tedium Measure (the Burnout Measure)• Physical, emotional and mental exhaustion

Symptoms DiseaseAbdominal Pain Addisonian crisis; diabetic ketoacidosis; hyperparathyroidismAmenorrhea or Oligomenorrhea

Adrenal insufficiency, adrenogenital syndrome, anorexia nervosa, Cushing’s syndrome, hyperprolactinemic states, hypopituitarism, hypothyroidism, menopause, ovarian failure, polycystic ovaries, pseudohermaphroditic syndromes

Anemia Adrenal insufficiency, gonadal insufficiency, hypothyroidism, hyperparathyroidism, panhypopituitarism

Anorexia Addison’s disease, diabetic ketoacidosis, hypercalcemia (e.g. hyperparathyroidism), hypothyroidism

Constipation Diabetic neuropathy, hypercalcemia, hypothyroidism, pheochromocytomaDepression Adrenal insufficiency, Cushing’s Syndrome, hypercalcemic states, hypoglycemia,

hypothyroidismDiarrhea Hyperthyroidism, metastatic carcinoid tumors, metastatic medullary thyroid

carcinomaFever Adrenal insufficiency, hyperthyroidism (severe: thyroid storm), hypothalamic diseaseHair changes Decreased body hair (hypothyroidism, hypopituitarism,thyrotoxicosis); hirsuitism

(androgen excess states, Cushing’s Syndrome, acromegaly)Headache Hypertensive episodes with pheochromocytoma, hypoglycemia, pituitary tumors

Underlying Health Problems/Endocrine Disease?Referring to GP

Adapted from Basic & Clinical Endocrinology, (Gardner & Shoback, 2007).

Symptoms DiseaseHypothermia Hypoglycemia, hypothyroidismLibido changes Adrenal insufficiency, Cushing’s syndrome, hypercalcemia, hyperprolactinema,

hyperthyroidism, hypokalemia, hypopituitarism, hypothyroidism, poorly controlled diabetes mellitus

Nervousness Cushing’s syndrome, hyperthyroidismPolyuria Diabetes insipidus, diabetes mellitus, hypercalcemia, hypokalemiaSkin changes Acanthosis nigricans (obesity, polycystic ovaries, severe insulin resistance),

Cushing’s syndrome, acromegaly), acne (androgen excess), hyperpigmentation (adrenal insufficiency, Nelson’s syndrome), hypothyroidism, hypopigmentation (panhypopituitarism), striae, plethora, bruising, ecchymoses (Cushing’s syndrome), vitiligo (autoimmune thyroid disease, Addison’s disease)

Weakness and fatigue 

Addison’s disease, Cushing’s syndrome, diabetes mellitus, hypokalemia (e.g. primary aldosteronism, Bartter’s syndrome), hypothyroidism, hyperthyroidism, hypercalcemia (e.g. hyperparathyroidism, panhypopituitarism, pheochromocytoma)

Weight gain Central nervous system disease, Cushing’s syndrome, hypothyroidism, insulinoma, pituitary tumors

Weight loss Adrenal insufficiency, anorexia nervosa, cancer of endocrine glands, hyperthyroidism, type 1 diabetes mellitus, panhypopituitarism, pheochromocytoma

Underlying Health Problems/Endocrine Disease?Referring to GP

Adapted from Basic & Clinical Endocrinology, (Gardner & Shoback, 2007).

12 Phases of Burnout

Freudenberger & North

Twelve-phase model of Herbert Freudenberger and Gail North (1992). The 12 phases are depicted in the abbreviated form; see text for more details (Source: Coaching, Empirical Social Research and Gender Research, 2013).

Burnout is a Multi-Dimensional Syndrome

How to Cope?

Prevention: Awareness, Balance, Connection

Tips for Companies• Instead of “burnout prevention” training, consider “work

engagement” angle• If using employee surveys, assess for employee

engagement instead of burnout• Consider professional supports of younger staff/new to

the career (Mentoring)?• Induction: Health Promotion: Red Flags• Manager Training: Emotional Intelligence focus

(Coaching needed?)• Respect & support recovery time of individuals• Return to Work: Immediate contact + ongoing!

Tips for CompaniesDemands ● Work Loads

● Work Patterns● Work Environment

Control How much say a person has in the way they do their work

Support Encouragement, sponsorship and resources provided by the organisation, line management and colleagues

Role ● Understanding role in the organisation● Conflicting roles

Change How it is managed and communicated?

Relationships(Dignity at Work)

Promote positive working to avoid conflict and dealing with unacceptable behaviour

Source: “How to tackle work-related stress: A guide for employers on making the management standards work” Health and Safety Executive UK

Psychological SupportsGuilt and Shame: It’s most likely not about YOU• Assess for perfectionism/personality traits• Current life situation (Life Span)• Personal resources: Coping skills, family, friends, skills

set• Digital Detox• Let Go and Let Grieve: Bereavement, confronting as

PTSD

Tips for IndividualsRebuilding self-esteem is a key element of the rehabilitation of burned-out employees.

Psychological Resilience/Mental Fitness

Physical FitnessIncrease in job burnout and depression strongest among employees who did not engage in physical activity and weakest to the point of non-significance among those engaging in high physical activity (Toker & Biron, 2012).

Assess for Addictions• Gambling• Risky Sexual Behaviours• Over-Reliance on

Prescription Meds? (Benzos)

• Alcohol/Drugs• Disordered Eating• How much is too much?

Impact on functioning?

Our individual life situations and perspectives are unique....and

complex

Not just one particular cause...Consider scope of additional stressors,

treatment should be person-centred.

Find your Groove

• Slow down• Interests and aptitudes• Time Management/Priorities• Assertiveness• Confidence building• Redefining the self• Body Awareness• Mindfulness/Relaxation• Don’t be a martyr: Look into Assertiveness Skills• Learn how to identify, avoid and cope with Emotional

Vampires in your personal

Important Tips

Especially when in

Recovery from BurnoutWhat is really within your control or how can you

change how you perceive it or deal with it?

Return to Work Coordination, Counselling, Coaching, Workshops & Training, Job AnalysisWeb: www.southdublincoaching.com

Email: southdublincoaching@gmail.com

Suggested ReadingThe Joy of Burnout: How Burning Out Unlocks the Way to a Better, Brighter Future (2007) Dr Dina Glouberman Burnout for Experts (

Burnout for Experts: Prevention in the Context of Living and Working (2013)Bahrer-Kohler (Ed).

Mindful Path to Self Compassion (2009) Christopher Germer

High Octane Women: How Superachievers Can Avoid Burnout (2010) Sherrie Bourg Carter, PsyD

Primal Leadership: Learning to Lead with Emotional Intelligence(2004)Daniel Goleman, Richard E. Boyatzis, and Annie McKee.

ResearchCauses of burnout are multidimensional and can be categorized into three groups: organisational, job-related and individual factors (Shirom, 2003).

“Feeling types” more prone to burnout than “thinking types,” especially in relation to cynicism (Maslach, Shaufeli, & Leiter, 2001).

Performance based self-esteem is a predictor and a consequence of burnout (Dahlin, Joneborg, & Runeson, 2007; Rosse, Boss, Johnson, & Crown, 1991). Associated with poor health including hypertension, alcoholism, myocardial infarction (Shanafelt et al. 2006;  Väänäenet al. 2008, Alves et al. 2009), cardiovascular, musculoskeletal, skin, and allergic diseases including somatic co-morbidtiy (which increases with burnout).

Work overload linked to high cholesterol (Melamed, Shirom, Toker, & Shapira,2006).

Burnout is associated with musculoskeletal diseases among women and with cardiovascular diseases among men (Honkonen, et al; 2006).

Emotional exhaustion is considered to be the most important dimension of burnout syndrome (Roelofs et al. 2005).  

Burnout and DepressionBurnout often associated with depression (Ahola & Hakanen, 2007; Bianchi, Schonfeld, & Laurent, E., 2015; Hintsa et al., 2014)

Job strain predisposes to depression through burnout. In comparison, job strain causes a predisposition towards burnout directly and via depression (Ahola & Hakanen, 2007).

A predisposition for depression, as reflected by a personal and familial history of depression, may enhance the risk for burnout (Nyklicek & Pop, 2005).

Raised inflammatory markers in depression (Glassman & Miller, 2007) Association between job strain and depression is stronger for women (Mausner-Dorsch and Eaton 2000).

Association between burnout and depression particularly based on emotional exhaustion component of the MBI (Ahola et al., 2005; Nyklicek & Pop, 2005; Peterson et al., 2008).

Risk of having a depressive disorder greater when burnout severe compared to mild or no burnout (Ahola, et al., 2005).

ReferencesAhola, K., & Hakanen, J. (2007). Job strain, burnout, and depressive symptoms: a prospective study among dentists. Journal of Affective Disorders, 104 (1-3): 103-110.  Alves, M.G., Chor, D., Faerstein, E., Werneck, G.L., & Lopes, C.S. (2009). Job strain and hypertension in women: Estudo Pro-Saúde (Pro-Health Study). Revista de Saúde Pública, 43, 893-896. Bianchi, R., Schonfeld, I.S., & Laurent, E. (2015). Is burnout separable from depression in cluster analysis? A longitudinal study. Social Psychiatry and Psychiatric Epidemiology, 50(6), 1005-11.  Dahlin., M., Joneborg, N., & Runeson, B. (2007). Performance-based self-esteem and burnout in a cross-sectional study of medical students. Medical Teacher, 29(1), 43-48.  Figley, C.R. (Ed). (1995) Compassion fatigue: Coping with secondary trauma disorder in those who treat the traumatized. New York: Brunner/Mazel Glassman, A.H., & Miller, G.E. (2007). Where there is depression, there is inflammation....sometimes! Biological Psychiatry, 62 (4), 280-81. Hintsa, T., Elovainio, M., Jokela, M., Ahola, K., Virtanen, M., & Pirkola, S. (2014). Is there an independent association between burnout and increased allostatic load? Testing the contribution of psychological distress and depression. Journal of Health Psychology, pii: 1359105314559619. [Epub ahead of print] Honkonen, T. Ahola, K., Pertovaara, M., Isometsa, E., Kalimo, R., Nykyri, E., Aromaa, A., & Lonnqvist, J. (2006). The association between burnout and physical illness in the general population- results from the Finnish Health 2000 Study. Journal of Psychosomatic Research; 61(1): 59-66.

ReferencesMaslach, C., Schaufeli, W.B. and Leiter, M.P. (2001), Job burnout. Annual Review of Psychology, Vol. 52 No. 1, pp. 397-422.

 Mausner-Dorsch, H., & Eaton, W. (2000). Psychosocial work environment and depression: Epidemiologic assessment of the demand-control model. American Journal of Public Health, 90, 1765-1770.

 Nyklicek, I., & Pop, V.J. (2005). Past and familial depression predict current symptoms of professional burnout. Journal of Affective Disorders, 8(1), 63-8.

 Roelofs, J., Verbraak, M., Keijsers, G.P.J., de Bruin, M.B.N., & Schmidt, A.J.M. (2005). Psychometric Properties of a Dutch version of the Maslach Burnout Inventory General Survey (MBI-DV) in individuals with and without clinical burnout. Stress and Health, 21, 17-25.

 Rosse, J.G., Boss, R.W., Johnson, A.E., & Crown, D.F. (1991). Conceptualizing the role of self-esteem in the burnout process. Group & Organization Management, 16(4), 428-451.

 Shanafelt, T., Chung, H., White, H., & Lyckholm, L.J. (2006). Shaping your career to maximize personal satisfaction in the practice of oncology. Journal of Clinical Oncology, 24, 4020-4026.

 Melamed, S., Shirom, A, Toker, S., & Shapira, I. (2006). Burnout and risk of type 2 diabetus: a prospective study of apparently healthy employed persons. Psychosomatic Medicine, 68 (6): 863-9.

Shirom, A. (2003). Job-related burnout. In J.C. Quick& L.E. Tetrick (Eds.) Handbook of occupational health psychology, (pp. 245-265). Washington, DC: American Psychological Association.

Väänäen, A., Koskinen, A., Joensuu, M., Kivimaäki, M., Vahtera, J., Kouvonen, A., et al. (2008). Lack of predictability at work and risk of acute myocardial infarction: An 18 year prospective study of industrial employees. American Journal of Public Health 98, 2264-2271.  

According to the American Psychological Association (2014), the signs of burnout include:• Loss of pleasure in work• Depression (sleep or appetite

disturbance, lethargy, negative mood)• Inability to focus or concentrate;

forgetfulness• Anxiety• Substance use/abuse or other compulsive

behaviours to manage stress• More frequent clinical errors• Less contact with colleagues• Workaholism• Persistent thoughts about clients and

their clinical material• Intrusive imagery from clients’

traumatic material• Increased cynicism, overgeneralised

negative beliefs• Increased isolation from or conflict with

intimates• Chronic irritability, impatience• Increased reactivity and loss of

objectivity and perspective in work• Suicidal thoughts