Processes operating in chronic burnout

The consequences of burnout may be severe both in terms of distress, finance, career progression and self-esteem. When illnesses carry severe consequences of this nature, sufferers will often adopt measures to try to reduce the likelihood of symptoms returning or worsening. This is especially relevant if, as suggested by research, symptoms are chronic in nature. Workers’ attempts to avoid an increase in levels of burnout will be based on their own beliefs about how burnout is caused and how it can be prevented. Such beliefs are likely to be based on the worker's own experience of burnout. They may also be influenced by the current societal beliefs and popular literature about burnout. These conceptualize burnout as a response to prolonged exposure to stress which is best managed by improved self-care. Therefore, care is taken in an effort to reduce the levels of demands to which they are exposed and to conserve resources wherever possible.

One qualitative study interviewed nurses who had recovered from ‘near burnout’ and found they believed a crucial method of avoiding further burnout was to ‘listen more carefully to the signals’ of their condition (Vinje & Mittelmark, Reference Vinje and Mittelmark2007, p. 110). Certain sensations, both emotional and physical, are associated with the last experience of burnout and therefore considered to be warning signs. A worker who is concerned about burnout is likely to engage in self-monitoring for these signs.

It is useful to explore in more detail how a worker in the ‘helping professions’ might try to reduce his/her exposure to stressors. Within the workplace, avoidance of potential stressors could constitute limiting certain types of patients, limiting the numbers of patients seen, restricting the degree of emotional engagement with a patient and avoiding any unnecessary involvement in the wider service. This strategy of avoidance is reminiscent of Maslach's description of the dimension of depersonalization in burnout as ‘the person who is experiencing a high level of cynicism tends to withdraw from the job and do the bare minimum, rather than strive to do the very best’ (Maslach, Reference Maslach2003, p. 191). Outside the workplace the need to avoid exposure to stress might cause withdrawal from any further emotional demands. This might include withdrawal from relationships where others need support. Norcross & Guy (Reference Norcross and Guy2007) noted some health professionals withdrew from friends and family in an attempt to manage the stress of listening to patients all day. Similarly, any situations viewed as draining might be avoided, thus limiting leisure activities. Rest and sleep might be prioritized over any other activity.

These strategies are intended to be adaptive coping strategies. But what is the effect of continual reliance on such strategies? Such continual focus on the conservation of resources will lead to a life increasingly focused on work, restricted in diversity, limited in social support and increasingly vigilant for signs of increasing burnout. Ironically this will lead to a situation far from the ideal work–life balance promoted by self-care literature. Sensations associated with fatigue will be interpreted as warning signs and these become the guide for setting limits on work. Once these limits are made, the worker will continue to assume that he/she will increase his/her level of burnout if they are exceeded. Therefore the worker is prevented from being able to regain a sense of resilience to stressors. This is because there is no opportunity to discover that an increased exposure to sensations and stressors can be managed by the worker. In this way these strategies, which may initially have been adaptive coping strategies, serve to maintain a worker's belief that he/she does not have the capacity to meet demands and thus in time become a safety behaviour that prevents recovery.

This response – of limiting activities, withdrawing from stressors and increased monitoring for symptoms – would be similar to attempts by some patients to manage pain, according to the fear-avoidance model of chronic pain (Vlaeyan & Linton, Reference Vlaeyen and Linton2000). This model describes how patients avoid activities assumed to increase the risk of pain or re-injury and remain hypervigilant to pain-related stimuli. It is also similar to the management strategies used by those suffering from chronic fatigue syndrome, where patients consider ‘anything that exacerbated symptoms was considered to be harmful or to increase the risk of relapse’ (Suraway et al. Reference Surawy, Hackmann, Hawton and Sharpe1995, p. 536). Both these models demonstrate that these coping strategies, which may be adaptive in an acute phase, paradoxically worsen the problem in the long term.

A model for the maintaining processes in burnout

A proposed CBT model for the maintaining processes of long-term burnout is shown in Figure 1.

Fig. 1.

A cognitive behavioural model of the maintaining processes in burnout.

In this model beliefs about burnout are generated by past experience of burnout and general views held by society. These beliefs dictate the need to monitor for signs of emotional fatigue and to minimize exposure to stressors.

As shown in the model, this resulting hypervigilance for sensations of emotional fatigue increases the degree of fatigue that is brought into conscious awareness. The effect of increased vigilance on increased awareness of fatigue has been demonstrated empirically in chronic fatigue syndrome (Moss-Morris et al. Reference Moss-Morris, Wash, Tobin and Baldi2005). Attention is focused on these signs rather than on any signs or feelings of coping. These sensations are interpreted as a danger sign for burnout rather than a passing feeling or a sensation within the normal range of tiredness or an appropriate sensation for the context.

Once identified, these sensations of emotional fatigue will trigger negative automatic thoughts such as ‘I can't cope’ and ‘I can't go on like this much longer’. These thoughts lead to increased attempts to avoid stressors in accordance with the beliefs held about prevention of burnout. As discussed, this prevents the worker from discovering they have a greater capacity to cope with the stressor than believed.

Furthermore, as avoidance leads to a decrease in tasks attempted, it is likely to affect a worker's view of his/her own performance. Performance will be evaluated less positively, leading to a reduced perception of a worker's own self-efficacy, another core dimension of burnout.

Both the reduced self-efficacy and the failure to disconfirm fears act to strengthen negative thoughts. This perceived inability to meet demands fulfils the definition of stress (Lazarus & Folkman, Reference Lazarus and Folkman1984) and this ongoing stress in turn increases emotional fatigue, the central dimension of burnout.

Implications for treatment and practice

So how does one distinguish between safety behaviours which may be maintaining a fear of burnout from those behaviours which constitute positive self-care? Adequate self-care is extremely important for healthcare professionals. In fact, this is one of the skills sometimes taught to patients. It is important to note that this model does not advocate against it. It does not imply that exhausted workers who take some time off are engaging in an unhelpful behaviour.

Instead, this model demonstrates that behaviours that are initially adaptive, may become unhelpful over time. The possibility of behaviours changing their effect in this manner is consistent with the view of Thwaites & Freeston (Reference Thwaites and Freeston2005) who stated ‘with repeated, excessive or situationally inappropriate use, it is possible that behaviour shifts along a continuum from adaptive coping strategy to safety behaviour’ (p. 178).

To distinguish safety behaviours from adaptive self-care strategies, safety behaviour may be defined as those behaviours that are responsible for maintaining negative thoughts about the capacity to cope. Rather than facilitating a graded return to the workplace, safety behaviours prevent any increase in recovery. Thwaites & Freeston consider the intention of behaviours as differentiating between safety behaviours and adaptive coping strategies. Safety behaviours and their accompanying cognitions are limiting and static rather than being intended to support increased exposure to stressors.

Safety behaviours can be elicited by asking how a worker responds or manages thoughts such as ‘I can't cope’. As with generic CBT, a questioning or experimental stance can be adopted and behavioural experiments can be used to test out both the thought and the need for the safety behaviour.

As an example of this approach, the thought ‘I am unable to cope with the full demands of this job’ can be tested by naming the full demands of the job, being specific about what it means to ‘cope’ and then testing the validity of this thought. The worker may report that they have limited their work in some part of their job in accordance with this thought. A behavioural experiment could be set up in which such a safety behaviour is dropped. (This should not imply that professionals should aim to work outside the limit of the competencies in accordance with codes of ethics.) For some workers recovering from burnout, the emphasis will be on coping with a gradually widening level of demand.

Case vignette

Therapist A had struggled with burnout at several points of her career. Due to this she had tried changing posts and taking extended time off work. However, although this relieved the immediate problem it did not provide a long-term solution. She continued to feel overwhelmed by work and was fearful of returning to a point where she might require further time off work.

Therapist A attempted to maximize her energy by avoiding phone calls from friends, avoiding any evening events on weekday nights and limiting the number of patients she saw in any day. In sessions and between sessions she would attend to any feelings of being overwhelmed, burdened, cut off from a patient or unsure how to direct the session. She would interpret these as signs that she was not coping with the emotional demands of the session.

Once she noted that these sensations continued despite a reduction in the demands she placed on herself she would think ‘This proves I cannot work to full capacity’; ‘I'm not very able’; ‘If I'm not able then I'm at risk of being overloaded’; ‘I need to be careful as I am vulnerable’. This resulted in a further withdrawal, hypervigilance and negative thoughts.

Change began with the thought ‘I cannot face Monday mornings, I won't be able to get through the sessions’. This was challenged by considering the evidence that she was already managing every Monday morning, albeit limiting her sessions. A new thought was generated: ‘I do face Monday mornings every week so I am able to face them’.

Once Therapist A had started to acknowledge her own ability to cope, her number of sessions on Monday morning was increased to test if she was still able to ‘face’ this work. As she continued to register her capacity to manage these stressors her negative cognitions regarding her capacity were replaced by the thought ‘I can cope’. Once she had returned to completing a full set of sessions she regained a sense of self-efficacy and her perception of emotional fatigue had diminished.

Congruence with research data

How does this fit with the research literature on burnout? Interestingly, the idea of dysfunctional coping strategies in the process of burnout has been raised in the research literature and most researchers agree that depersonalization, or reduced engagement in work, is a dysfunctional coping strategy (Kristensen et al. Reference Kristensen, Borritz, Villadsen and Christensen2005; Taris et al. Reference Taris, Le Blanc, Schaufeli and Schruers2005). In their study, Taris et al. (Reference Taris, Le Blanc, Schaufeli and Schruers2005) looked at the scores on the three dimensions of burnout over time. Their results suggested that emotional exhaustion was followed by high levels of depersonalization (withdrawal or avoidance) and that this depersonalization was a dysfunctional coping strategy that resulted in lower levels of personal accomplishment (efficacy) at a later date. As perceived efficacy decreased, so levels of burnout increased. This is congruent with the model proposed above, where awareness of emotional exhaustion leads to avoidance and withdrawal (akin to depersonalization), leading to reduced levels of personal accomplishment and a reinforcement of negative thoughts.

Further confirmation of this model could be obtained from conducting research into common beliefs about burnout and self-selected methods of ‘coping’ among those who suffer from burnout, particularly examining the use of avoidance and hypervigilance. This would determine how extensively these coping strategies are used. Additionally, this model suggests that those who engage in high levels of avoidance and hypervigilance will continue to suffer from burnout over time. Therefore it is expected such individuals will continue to report symptoms of burnout.

Summary

This CBT model of the maintaining processes in burnout highlights the danger of becoming caught in a cycle of maladaptive coping strategies that facilitates the enduring nature of burnout symptoms. It suggests the importance of identifying burnout-related thoughts and examining how coping strategies might be serving to reinforce them rather than ameliorate them. The identification and testing of these thoughts could form a useful tool both for individuals and supervisors of those who are struggling with the demands of their work, alongside the other self-care and systemic interventions currently being advocated.