Introduction
Burnout, dismissed by some as a drab 1960s concept, isn't going away. Despite not having official DSM-IV status, it continues to be empirically studied, theoretically described, and widely discussed by mental health professionals and the general public. Perhaps most importantly, it continues to be the defining focus of many patients, especially those who work in human service professions. These patients come to therapy complaining of work overload, exasperation at the innumerable and incessant demands in their lives, interpersonal problems, family difficulties, irritability, emotional and physical exhaustion, cynicism, and a belief that there is no way out of their situation. Many are doing relatively well financially and yet feel that although they can barely tolerate their work, co-workers and/or clients and barely feel like they have a life to themselves, they still cannot afford to leave and look for employment elsewhere. They are stuck, angry and disillusioned and often desperate for help – even when they believe no solutions are possible.
Definition of Burnout
Many definitions of burnout have been proposed; most tend to rely on delineating three central factors—emotional exhaustion, lack of personal accomplishment, and depersonalization (recently reconceptualized as "cynicism"). (Malakh-Pines, 1989)
Shirom (1989), for example, views burnout as a combination of physical fatigue, emotional exhaustion, and cognitive fatigue. The point is that burnout is about "inconsistency" - the perception by human service professionals that their efforts to help others have been ineffective, that the task is endless, and that they are not rewarded for their work. moral reward in terms of success, recognition or appreciation. (Shirom, 1989)
Contributors to the same journal offer several visions for working with clients who are burned out or on the verge of burnout. For Friedman, who has done extensive empirical work on the nature of burnout in teachers and school principals, the cure lies in healing the discrepancy between unrealistic expectations and self-perceived outcomes. "At some point," he notes, teachers learn the harsh truth, "...that they cannot meet their own performance expectations. And those placed on them by the system/supervisor." He offers several suggestions, including one that is consistent with cognitive therapy: the need for teachers to "not dwell on failures and mistakes." As already it is important to mention, regarding the work ethic, when making mistakes is expected, as their absence indicates in many cases work apathy. (Friedman, 2000)
Reflecting on clinical work with demoralized diabetic patients suggests the need for an eclectic model that includes empathic listening, cognitive interventions, focus as self-psychology, on the client's grandiosity, and awareness of one's own emotional responses to work. (Barbara Tilden, 2005)
Unlike many disorders categorized by the DSM-IV, burnout was considered a psychosocial rather than a psycho-physiological disorder. This means that those trying to understand burnout, rather than looking at the interaction between biogenetic factors and the environment—as might be done in the case of depression—have instead focused on the interaction between more salient personality characteristics (such as a high need for achievement) and external stressors (both organizational and societal). Thus, the nature of burnout can change when social pressures change, leading to the following hypothesis: while idealism reigned as the main cultural value 30 years ago, now ego-oriented, self-centered motives, including the pursuit of status and money, which serve as motivators for hard work, change the meaning and nature of the phenomenon called burnout. (Nagoski, 2020)
Burnout was first described in the late 1960s and early 1970s, a time of considerable social upheaval. It was also a time of strong social engagement among large groups of young individuals, especially human service professionals—those who work face-to-face with troubled and needy clients.
Freudenberger's (1974) early description of burnout involved young men and women working with drug addicts in a community medical clinic on the Lower East Side of New York City. His portrait depicted highly idealistic young people working harder and harder to uphold noble ideals and refusing to let up until they were at the point of virtual collapse. They believed in social causes larger than themselves—beliefs that sustained them and made them vulnerable to the cumulative effect of chronic overwork, especially given the small rewards for their efforts. For a while, the reward of feeling like they were doing good work, important work, was durable enough, but the lack of enough positive results eventually proved demoralizing. Despite their intensive and well-intentioned efforts, many of their clients did not improve; some of their physical and mental conditions were actually deteriorating. It seemed to them that their efforts did not make as much of a difference in the neighborhood and the city as they expected. (Freudenberger, 1974)
Development and changes in types of burnout
Teachers are probably a prime example of this type of burnout. Many young men and women entered the education system in the late 1960s, fueled by wonderful, if naive, expectations of the changes they would bring to the lives of the children they worked with. Some of these teachers have made impressive changes in the lives of their students and continue to work hard. Some who were disappointed with what they had achieved remained in teaching by limiting their unrealistic expectations and/or their efforts. Others did not change their expectations and therefore could not stay because the perceived output in terms of personal satisfaction or student performance no longer matched the perceived input. This was a burnout group—a group that eventually lost interest, stopped working hard, and suffered physically and emotionally from job stressors that were no longer mediated by sufficient satisfaction. For the most part, however, this is no longer the typical image of a burned-out worker. (Miyakoski, 2022)
Over the past 20 to 30 years, there have been countless cultural changes. Some of this is, of course, economic: a greater focus on profits has led to downsizing in many institutions and corporations and, in turn, increased workloads for workers in occupations ranging from nursing to university professors. Additionally, responsibility, results, and instant success are terms that can be heard in virtually every field of work today, even in human service occupations such as teaching and psychotherapy. Workers are now being asked to do more and more for less and less. These contemporary values are exactly what human service professionals were trying to escape two and three decades ago; unfortunately, human "service" in this age usually occurs in these contexts. (Wu, 2022)
Workplace culture has become increasingly technological. In addition, technology - especially the use of computers - has changed the nature of work and interpersonal relationships. Work can be, and often is, done in solitude; many actually prefer this arrangement. E-mail correspondence replaced face-to-face interactions and discussions; for some, computer solitaire has replaced group coffee breaks. These shifts also make it difficult to feel idealistic about your work or derive more meaning from it. Other changes occurred in the area of personal values; some of these changes may also be a function of the economic, technological and cultural changes mentioned above. Apathy, nihilism and/or self-interest have largely replaced devotion to social causes; that is, fewer individuals today than a generation ago seem committed to larger social issues, and thus finding greater meaning in work (beyond the purely financial) is increasingly difficult. One might even argue that the ironic and detached perspective of postmodernism contributed to this process. Certainly, the phrases we all hear too much - "it doesn't make any difference", "it doesn't matter" and "it doesn't matter" - all indicate a sense of detachment and conflict with the values embodied in earlier personal visions that emphasized a shared motivated work community. (Lal, 2022)
Thus, the shift towards using work primarily for personal gain, especially financial success, has largely replaced personal investment in work and the search for meaning. That means, "How much will I get paid?" it has largely replaced the question "Will this work provide personal meaning or fulfillment?" as a question asked by workers, even new ones. Likewise, in an effort to "have it all," individuals seem to overload themselves with an extraordinary amount of responsibilities. Individuals today are likely to complain to their therapists (and friends) about the overwhelming demands on their lives—the pressures of family, friends, work, and civic responsibilities. The most common complaint we all hear from family, friends, and clients is "I have so much going on right now. I can't keep up."
These are, of course, broad societal trends and exceptions to individual values; however, these shifts have greatly altered the general nature of the social contexts of work. One consequence of these changes is that individuals are less prone to the "classic" type of burnout—the kind in which they work harder and harder, to the point of physical and emotional exhaustion, in pursuit of lofty, often socially meaningful goals. Instead, the type of burnout that seems more prevalent today is characterized by individual complaints of multiple responsibilities, increasing external pressure, inadequate financial rewards, and insufficient opportunities for personal growth. There is a big difference between teacher A in the 1960s who complained, "It bothers me so much that despite my best efforts, many of my students still don't read well," and teacher B in the 2010s who complained, "There is so much pressure on me to make all my students do better on the next standardized test." Or compare the therapist of 20 or 30 years ago who complained that he no longer believed in the work—that clients weren't getting better—to the therapist today who complains instead of burning out about having to deal with the demands of managed care or the pressures of juggling multiple responsibilities in life. Or compare the lawyer of years ago who was disheartened by the fact that the practice of law was not what he expected in terms of personal development, to the lawyer today who routinely works 80-100 hour work weeks for enormous compensation, but is troubled by the feeling that he cannot find a way out of this "golden shackles" dilemma.
But the point is that the burnout we often saw ten or twenty years ago was usually based on a sense of inner disappointment—of not meeting goals at work (most often about helping others) that a person has set as personally and socially meaningful. Today's burnout is more often caused by the pressure to meet the escalating demands of others, or intense competition to be better than others in the same organization or company, or the drive to earn more and more money, or the feeling of being deprived of something that one clearly deserves. Yes, we still hear about nurses and doctors who are depressed because the conditions in their hospitals make it impossible to care for patients the way they wish, and about therapists who are angry with managed care not because of the loss of income, but because of the limitations in providing it - e.g. a treatment that they believe best suits the needs of their patients, but its implementation is not possible for material-technical reasons (or others). Instead, we hear more often about the impossibility of continuing to practice for reduced pay, or outrage at the addition of an extra ten minutes of work time for teachers at the end of the school day. Indeed, burnout caused by the perception of "I want it and I have the right to it" seems very far removed from the idealism on which the concept of defining burnout was born. Burnout, once a phenomenon associated with the inability to achieve one's idealistic goals, now appears to reflect failure to achieve one's own interests. And while it could be argued that the earlier idealistic visions were in many ways selfish (and unrealistic), the expectations of work during this more recent period more often reflected the need to feel personally fulfilled through helping others. (Stoeber & Lavinia, 2016)
Possible methods of therapy for contemporary burnout
Working therapeutically with this newer version of burnout is challenging—often for the same reasons that narcissistic individuals are difficult to treat. They don't want to be there; if they come to therapy, they are rarely willing to see their part in the dilemma; they almost always want to blame others for their problems or dysphoric feelings: "The boss is unfair," "My spouse doesn't appreciate how hard I work," "I never have time to take care of my own needs." All this is true, of course; this is all only part of the story, of course. One particular dilemma that therapists face is that encouraging this new brand of burnout individuals to reduce their commitments often leads to resistance. Although they suffer from the traditional symptoms of burnout (including emotional and physical exhaustion and cynicism towards others), they "want it all" and are reluctant to give up any aspect of their lives that leads to actual or potential narcissistic satisfaction. (Mojallal, 2022)
Suggestions for possible therapy in this situation include aligning with the burned-out individual: "Yes, you are overworked; yes, you are underappreciated." Unless and until that person feels heard and validated, no therapeutic work is likely to not only be completed, but to begin. Only gradually can the therapist begin to move towards issues of personal responsibility, values, expectations and meaning. Clinical work with such individuals usually involves four aspects, each of which usually requires a combination of psycho-dynamic and cognitive-behavioral perspectives:
- forcing the individual to adjust their expectations about what work (and others at work) can and cannot provide in terms of meaning and fulfillment;
- getting the individual to focus on the positive aspects of the job and not just the oppressive, burdensome parts;
- to force the individual to build a stronger support network to mediate the inevitable stressors of work (sports, art, etc., be careful, it is important to avoid negative ways such as, for example, the abuse of addictive substances); and lastly
- working with individuals with the aim of taking better care of themselves and others in non-work areas, so that stressors from work are not always at the forefront - being able to detach from work. (Moss, 2022)
Conclusion
The nature of work and the nature of the culture in which it is embedded is constantly evolving; a lot has changed in society over the last 20 to 30 years - in the last 5 years as well. Thus, the roles and focus of therapists treating burnout must change as the nature of the disorder also changes over time. More therapists are now able to, and should, draw on a growing diversity of theoretical perspectives when dealing with issues related to burnout. Individuals who suffer from burnout or are concerned that they may be exposed to it also have some basic recommendations that can be followed. Finally, it is important to mention self-hygiene and self-care.
Author: Lt. MSc. John Janek
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