Protecting the professionals treating PTSD patients from burnout

How the Department of Veterans Affairs can take care of providers, so they can take care of patients.

For many mental healthcare clinicians at the US Department of Veterans Affairs (VA), listening to accounts of horrific, traumatic experiences is a routine part of the job. This type of work can be disturbing. There’s also another stressor VA mental health providers face: organizational politics and bureaucracy. Hector Garcia is a VA researcher and clinical psychologist. He explains the importance of taking care of providers, so they can take better care of patients.

ResearchGate: What is burnout?

Hector Garcia: Various models for burnout have been suggested, but the most widely used model for understanding burnout, put forth by Christina Maslach, includes three factors: first, emotional exhaustion created by work demands; second, cynicism or indifference about work, often arising as a protective reaction to emotional exhaustion; and third, low professional efficacy, or the sense that one is incapable of fulfilling job responsibilities. Our team has also studied absenteeism and intent to leave one’s position as proxies for burnout.

RG: How do burnout rates in mental health professionals compare to other professions?

Garcia: Burnout can occur in any profession. Even so, research has found that occupations requiring “emotion work”—work requiring frequent display or suppression of emotion, or frequent empathy—create stress above and beyond typical workplace stressors.

RG: How does hearing about veterans’ traumatic experiences affect the providers treating them?

Garcia: Our research found that providers specializing in PTSD can feel disturbed by what they hear. Sometimes working with trauma victims can cause what is known as vicarious traumatization or secondary traumatic stress, where providers begin to experience symptoms similar to their patients’. However, our research largely did not find vicarious traumatization or secondary traumatic stress among VA providers. What was found was the impact of organizational stressors on burnout. More research is on this topic is needed, however.

RG: Are VA providers exposed to more traumatic experiences than other mental health professionals?

Garcia: Generally, yes, particularly those working on PTSD Clinical Teams, which are VA’s PTSD specialty clinics. For these clinicians, whose caseloads are almost exclusively comprised of veterans with PTSD, regular vicarious exposure to horrific traumatic material is the norm.

RG: What impact does this have on patients?

Garcia: There is literature showing that providers struggling with burnout may provide lower quality mental health care. The good news is that our research consistently found that, despite high cynicism and exhaustion, VA mental health care workers score high on professional efficacy—meaning many feel the care they are providing is effective. Independent reviews have found that the quality of VA mental health care typically equals or exceeds care provided in non-VA settings, which would seem to corroborate providers’ perceptions.

RG: Does the type of therapy matter in terms of how much providers are affected?

Garcia: In one of our studies we looked at time spent conducting two evidence-based psychotherapies for PTSD: cognitive processing therapy and prolonged exposure. Prolonged exposure involves intensive vicarious trauma exposure in nearly every session. Neither evidence-based psychotherapy method (nor non-evidence-based treatments) predicted burnout, despite the differences in trauma exposure. Still, this was only one study, and more research is needed to understand the impact of specific treatments on providers at VA.

RG: What are some of the organizational stressors that contribute to provider burnout?

Garcia: To date, a robust predictor of burnout across our research has been VA organizational politics and bureaucracy. We have preliminary findings showing that worry about vulnerability to complaints to Congress, VA leadership, and the media, predicts burnout in VA providers. Because of VA’s unique position in the executive branch of government, such stressors are not commonly experienced in non-VA settings. And despite the fact that numerous independent assessors highlight the high quality of VA healthcare, inaccurate or disproportionately negative media coverage is common. Such coverage fails to convey the positive aspects of VA care. For providers who strongly identify with VA’s mission of helping improve veterans’ lives, such portrayals can be demoralizing. Further, negative media often triggers direct policy intervention by Congress, and many employees feel overwhelmed by frequent changes in policy, and an overabundance of metrics that sometimes distract providers from what they do best – patient care.

RG: What can the VA and other institutions do to support mental healthcare providers and ensure quality patient care?   

Garcia: In line with prior studies, our findings suggest that low sense of control over one’s work significantly contributes to occupational burnout. This suggests that restoring providers’ sense of personal control can go a long way toward inoculating against stress and improving organizational health. Allowing time outside of direct clinical care for activities such as research, teaching or supervision, may also be protective, particularly for mental health providers who expend a great deal of time performing “emotion work.” Fostering trust in colleagues and leadership is also crucial, as is managing workload.

There are many positive aspects of working at VA, such as good incentives and job security. Another strength is mission buy-in, a measure of job satisfaction and organizational health; independent assessors consistently find high employee commitment to VA’s mission of serving veterans. Further, US Secretary of Veterans Affairs Robert McDonald recently identified employee engagement as a core priority at VA, and set in motion several initiatives aimed at fostering a healthy VA organizational culture. Continued research into factors influencing burnout and engagement are needed to inform VA efforts, and the role of VA politics must be considered.

Providers want to experience engagement and satisfaction in their work, and evidence suggests that taking care of providers helps them to take better care of patients. Provider burnout should therefore be understood as an issue of critical importance in healthcare policy and research.

Featured image courtesy of Michael Clesle.