Occupational burnout

Diagnosis

Burnout is not recognized as a distinct disorder in the DSM-5. However, it is included in the ICD-10 but not as a disorder. It can be found in the ICD under problems related to life-management difficulty (Z73).

Social psychologists Christina Maslach and Susan Jackson developed the most widely used instrument for assessing burnout, namely, the Maslach Burnout Inventory. The Maslach Burnout Inventory operationalizes burnout as a three-dimensional syndrome made up of exhaustion, cynicism, and inefficacy. Some researchers and practitioners have argued for an "exhaustion only" model that views that symptom as the hallmark of burnout.

A growing body of evidence suggests that burnout is clinically and nosologically similar to depression. In a study that directly compared depressive symptoms in burned out workers and clinically depressed patients, no diagnostically significant differences were found between the two groups; burned out workers reported as many depressive symptoms as clinically depressed patients. Moreover, a study by Bianchi, Schonfeld, and Laurent (2014) showed that about 90% of burned out workers meet diagnostic criteria for depression, suggesting that burnout may be a depressive syndrome rather than a distinct entity. The view that burnout is a form of depression has found support in several recent studies.

The term "responder apathy syndrome" (RAS) refers to a controversial psychological diagnosis connected to occupational burnout that is not recognized by most physicians or psychologists. Originally developed to explain the apathy seen in paramedics and firefighters toward those calling for their help, the definition has generally been expanded to include nurses, respiratory therapists and other health care workers involved in direct patient care. Generally diagnosticians term the symptoms as generalized burnout and ignore the occupation specific burnout termed RAS.

Causes

Evidence suggests that burnout's etiology is multifactorial in nature, with dispositional factors playing an important role. One cause of burnout includes stressors that a person is unable to cope with fully. Occupational burnout often develops slowly and may not be recognized until it has become severe. When one's expectations about a job and its reality differ, burnout can begin. How pressure is dealt with determines how much stress someone feels and how close they are to burnout. One individual can experience few stressors, but be unable to handle the pressure well and thus experience burnout. Another person, however, can experience a far greater number of stressors, but effectively deal with them, and avoid burnout. How close someone is to a state of burnout can be determined through various tests.

Burnout is becoming a more common result as the modern workplace changes. Being both economically and psychologically exhausting, the increasingly hostile and demanding environments in which employees work is being studied as a cause. More frequently, economic values are placed ahead of human values. The phenomenon is more likely when a mismatch is present between the nature of the job and the person doing the job. A common indication of this mismatch is work overload. It involves doing too much with too few resources, going beyond personal limits. This may occur in a situation of downsizing, which often does not reduce a company's mandate, but allocates it to present employees.

The job-demands model of burnout proposes that burnout is influenced by job demands and job resources. Job demands are the physical and psychological costs of work, such as work pressure and emotional demands. Job resources are organizational aspects of the job that help employees manage job demands. A review by Demerouti et al. found that burnout can be explained by the two factors of job demands and job resources, and that exhaustion is correlated to job demands, and that job resources are negatively correlated to disengagement. Demerouti also showed that burnout is present in all types of jobs, and not just within human services.

Maslach, Schaufeli and Leiter identified six risk factors for burnout: mismatch in workload, mismatch in control, lack of appropriate awards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.

Burnout is supposed to be a work-specific syndrome. However, this restrictive view of burnout's scope has been shown to be groundless.

Phases

Psychologists Herbert Freudenberger and Gail North have theorized that the burnout process can be divided into 12 phases, which are not necessarily followed sequentially.

1. The compulsion to prove oneself Often found at the beginning is excessive ambition. The desire to prove oneself in the workplace turns into compulsion.
2. Working harder Because they have to prove themselves to others or try to fit in an organization that does not suit them, people establish high personal expectations. In order to meet these expectations, they tend to focus solely on work while they take on more work than they otherwise would. It may happen that they become obsessed with doing everything themselves to show that they are irreplaceable.
3. Neglecting their needs Since they have to devote everything to work, they now have no time and energy for anything else. Friends and family, eating and sleeping start to be seen as unnecessary or unimportant, as they reduce the time and energy that can be spent on work.
4. Displacement of conflicts They become aware that what they are doing is not right, but they are unable to see the source of the problem. This may lead to a crisis in themselves and become threatening. The first physical symptoms appear.
5. Revision of values While falling into a state of denial of basic physical needs, perceptions and value systems change. Work consumes all energy, leaving none for friends and hobbies. The job is the new value system and people start to become emotionally blunt.
6. Denial of emerging problems People may become intolerant and dislike being social. They may be seen as aggressive and sarcastic. Problems may be blamed on time pressure and all the work that they have to do.
7. Withdrawal Minimal social contact turns into isolation. Alcohol or drugs may be used as a release from obsessive working "by the book". These people often have feelings of being without hope or direction.
8. Obvious behavioral changes Coworkers, family, friends and others in their immediate social circles cannot overlook the behavioral changes in these people.
9. Depersonalization It is possible that they no longer see themselves or others as valuable. Their view of life narrows to only seeing the moment and life turns to a series of mechanical functions.
10. Inner emptiness They feel empty inside and may exaggerate activities such as overeating or sex to overcome these feelings.
11. Depression Burnout may include depression. In that case, the person is exhausted, hopeless, indifferent, and believes that life has no meaning.
12. Burnout syndrome They collapse physically and emotionally and need immediate medical attention. In extreme cases, suicidal ideation may occur, with it being viewed as an escape from their situation. Only a few people will actually commit suicide.

Effects

Symptoms of burnout include dysfunctional attitudes towards work, exhaustion, loss of motivation, distress, and feelings of ineffectiveness. Poor coping mechanisms can contribute to or result from burnout.

Many theories of burnout include negative outcomes related to burnout, including measures of job function (performance, output, etc.), health related outcomes (increases in stress hormones, coronary heart disease, circulatory issues), and mental health problems such as depression. It has been found that patients with chronic burnout have specific cognitive impairments, which should be emphasized in the evaluation of symptoms and treatment regimes. Significant reductions in nonverbal memory and auditory and visual attention were found for the patient group.

Usually occupational burnout is associated with increased work experience, increased workload, but also absences and time missed from work, it shows up as an impaired empathy and cynical attitudes toward clientele or colleagues, and thoughts of quitting.

At the individual level

It is difficult to treat the three symptoms of exhaustion, cynicism, and inefficacy, as they react to the same preventive or treatment activities in different ways. Exhaustion is more easily treated than cynicism and professional efficacy, which tend to be more resistant to treatment. Research shows that intervention actually may worsen the professional efficacy of one who originally had low professional efficacy.

For the purpose of preventing occupational burnout, various stress management interventions have been shown to help improve employee health and wellbeing in the workplace and lower stress levels. Training employees in ways to manage stress in the workplace have also proven effective in prevention of burnout. One study suggest that social-cognitive processes such as commitment to work, self-efficacy, learned resourcefulness and hope may insulate individuals from experiencing occupational burnout. Increased job control is another intervention shown to help counteract exhaustion and cynicism in the workplace.

Burnout prevention programs have traditionally focused on cognitive-behavioral therapy (CBT), cognitive restructuring, didactic stress management, and relaxation. CBT, relaxation techniques (including physical techniques and mental techniques), and schedule changes are the best-supported techniques for reducing and preventing burnout in a health-care specific setting. Combining both organizational and individual level activities may be the most beneficial approach to reduce symptoms.

Employee rehabilitation is a tertiary preventive intervention which means the strategies used in rehabilitation are meant to alleviate, as well as prevent, burnout symptoms. Such rehabilitation of the working population includes multidisciplinary activities with the intent of maintaining and improving employees' working ability and ensuring a supply of skilled and capable labor in society.

Additional prevention methods include: starting the day with a relaxing ritual; adopting healthy eating, exercising, and sleeping habits; setting boundaries; taking breaks from technology; nourishing one's creative side, and learning how to manage stress.

At the organizational level

While individuals can cope with the symptoms of burnout, the only way to truly prevent burnout is through a combination of organizational change and education for the individual.

Maslach and Leiter postulated that burnout occurs when there is a disconnection between the organization and the individual with regard to what they called the six areas of work life: workload, control, reward, community, fairness, and values. Resolving these discrepancies requires integrated action on the part of both the individual and the organization. A better connection on workload means assuring adequate resources to meet demands as well as work/life balances that encourage employees to revitalize their energy. A better connection on values means clear organizational values to which employees can feel committed. A better connection on community means supportive leadership and relationships with colleagues rather than discord.

One approach for addressing these discrepancies focuses specifically on the fairness area. In one study employees met weekly to discuss and attempt to resolve perceived inequities in their job. This study revealed decreases in the exhaustion component over time but did not affect cynicism or inefficacy indicating that a broader approach is required.

Stemming from Mayo's Hawthorne Studies, Employee assistance programs were designed to assist employees in dealing with the primary causes of stress. Some programs included counseling and psychological services for employees. There are organizations that still utilize EAPs today, but the popularity has diminished substantially because of the advent of stress management training (SMT). SMT is employed by many organizations today as a way to get employees to either work through stress or to manage their stress levels—to maintain stress levels below that which might lead to higher instances of burnout.