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DOCUMENT RESUME
ED 303 741 CG 021 440
AUTHOR Farber, Barry A.
TITLE Burnout in Psychotherapists: Incidence, Types, and
Trends.
PUB DATE Aug 88
NOTE 15p.; Paper presented at tte Annual Meeting of the
American Psychological Association (96th, Atlanta,
GA, August 12-16, 1988).
PUB TYPE Reports - Research/Technical (143) -- Viewpoints
(120)
EDRS PRICE MF01/PC01 Plus Postage.
DESCRIPTORS *Bqrnout; *Incidence; *Psychotherapy; *Stress
Variables; *Therapl.sts; *Trend Analysis
ABSTRACT Burnout among psychotherapists appears to be low;
most psychotherapists seem quite satisfied with their work and
untouched by the dysfunctional symptoms of burnout. Interviews with
60 therapists revealed that most considered "lack of therapeutic
success" to be the single most stressful aspect of therapeutic work.
Burnout was most often attributed to the nonreciprocated
attentiveness, giving, and responsibility demanded by the therapeutic
relationship. A survey of clinical psychologists suggests that
institutionally-based therapists, as opposed to those in private
practice, are more at risk of burnout. Three types of burnout which
have been identified among teachers can be used to construct profiles
of burned out psychotherapists. The most likely candidate for the
first type of burnout - frenetic overinvolvement - may be the young,
highly idealistic therapist. The second type, the worn-out therapist,
seems most prevalent among experienced therapists working in
institutions with oppressive bureaucratic structures. Finally, there
is the underchallenged, underestimated therapist. Trends which may
increase the risk of burnout among psychotherapists include the trend
toward health maintenance organizations, the trend for an increasing
number of individuals with difficult-to-treat character disorders
seeking treatment, and the tendency for psychotherapy to become more
of a business. (NB)
*Reproductions supplied by EDRS are the best that can be made *
*from the origir 1 document. *
Burnout in Psychotherapists: Incidence. Types. and Trends
Barry A. Farber, Ph.D.
Department of Psychology
Teachers College, Columbia University
New York, NY 10027
Paper presented at the Annual Convention: APA, Atlanta, August, 1988
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11I.-I
1
Therapist Burnout
- 10 1
Barry A. Farber, Ph.D.
Teachers College,
Columbia University
The problems with the term "burnout" have been well documented. It
has been overused, misused, adopted indiscriminately to describe
temporary states of disaffection with work, leisure activities,
relationships, and lives in general. But the word endures, for its essential
nature, its basic symptoms, resonate with a wide variety of workers,
including those who practice psychotherapy. Feelings of exhaustion, of
emotional and physical depletion, of inattention within the office and
irritability outside the office, of disillusionment and loss of belief in
one's effectiveness, of displacement of feelings onto one's family and
friends-these are phenomena that most of us have experienced, at least
occasionally. To label transient feelings of doubt or occasional bouts of
anger at borderline patients, "burnout", is, indeed to dilute the meaning of
the term. But the experience of these episodic feelings do enable us to
understand more fully the nature of thefull-blown syndrome, just as
fleeting feelings of sadness enable us to more fully empathize with those
with major depressive disorders.
Incidence and Risk Factors
While burnout in psychotherapists, then, is something many can easily
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Therapist Burnout
relate to, the numbers of those who are actually burned out in this field is
relatively low. In comparison to teachers, for example, few therapists are
burned out. If we think of burnout as more than a transient state, we can
compare prevalence rates by noting the percentages of those in each group
whose responses on the Maslach Burnout Inventory (MBI) indicate that they
have "frequently" felt burned out from work during the last month. On this
basis, 10.3% of suburban public school teachers are burned out and a
startling 21.6% of urban teachers (Farber, 1984), but only 1.6% of the more
than 300 clinical psychologists who responded to a 1985 surv4 (Farber,
1985).
Another method of computing relative prevalence rates is to compare
these psychologists' scores on the three subscales of the MBI with Maslach
and Jackson's (1981) reported norms on a large and varied sample of human
service professionals. The Emotional Exhaustion subscale of the MBI
includes such items as "I feel emotionally drained from my work," and "I
feel used up at the end of the workday." On the intensity dimension of this
subscale, 75% of therapists in this sample scored in the "low" (lower
third) range of experienced burnout and only 6% scored in the "high" (upper
third) range. A second subscale of the MBI, Depersonalization, includes
such items as "I feel I treat some recipients as if they were impersonal
objects" and "I've become more callous toward people since I took this job."
On this subscale, 74% of the sample placed in the low range and only 2.3%
in the high range. The third subscale of the MBI, Personal Accomplishment,
is comprised of such items as "I feel I'm positively influencing other
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Therapist Burnout
people's lives through my work," and "I have accomplished many
worthwhile things in this job." On this last subscale, 62% of therapists in
this sample had scores in the low range but somewhat surprisingly, 19.2%
of therapists scored in the high end of burnout-- a finding suggestive of
the fact that for a substantial minority of therapists psychotherapy
simply doesn't work as well as they would wish. As will be discussed
shortly, this somewhat disenchanted subgroup is probably
disproportionately represented by those working in institutional settings.
Overall, though, only 2% of therapists frequently feel emotionally drained
by their work, and only 2% frequently feel that working directly with
others puts too much stress on them. Most therapists then, seem quite
satisfied with their work, and except for perhaps 2-6% of the profession,
untouched by the dysfunctional symptoms of burnout.
What causes this small minority of therapists to burn out or causes
most of us to experience those transient feelings of despair? In-depth
interviews with 60 therapists have begun to provide answers to such
questions (Farber & Heifetz, 1982). Most of those interviewed cited "lack
of therapeutic success" as the single most stressful aspect of therapeutic
work; burnout per se was most often attributed to the nonreciprocated
attentiveness, giving, and responsibility demanded by the therapeutic
relationship. Other factors cited in accounting for burnout included
overwork, the general difficulty in dealing with patient problems,
discouragement as a function of the slow and erratic pace of therapeutic
work, the tendency of therapeutic work to raise personal issues in
I.)
4
Therapist Burnout
therapists themselves, the passivity oftherapeutic work, a -,d the isolation
often demanded by the work. The findings of this, and several other
studies, then, suggest that therapists expect their work to be difficult and
even stressful, but they also expect their efforts to "pay off." Constant
giving without the compensation of success apparently produces burnout.
Both patients and therapists art prone to burnout when they experience
their efforts as inconsequential.
Who among therapists is most likely to burn out? The survey of
clinical psychologists (Farber, 1985) suggests that institutionally-based
therapists, as opposed to those in private practice are more at risk. Both
on the Emotional Exhaustion and Personal Accomplishment subscales of the
Maslach Burnout Inventory, the scores of institutionally-based
practitioners as well as those with split practices are more indicative of
burnout. And less experienced therapists are also at greater risk for
burnout. First-order partial correlations indicate that number of years of
experience, even independent of age, is negatively and significantly re'ated
to scores on the Emotional Exhaustion and Depersonalization subscales.
Gender, however, does not seem to affect the tendency toward burnout.
Why are institutionally-based therapists more vulnerable to burnout?
Primarily because burnout is strongly mitigated by feelings of efficacy,
and such feelings are generally harder to come by for those whose hours
are dominated by chronic, resistant or seemingly untreatable patients. In
addition, those working in institutional settings are often faced with a
whole set of professional issues not encountered by those in private
E.3
5
Therapist Burnoue
practice. What immediately comes to mindilem is the issue of
"second-class" citizenship--deferring to those with medical degrees, even
when their knowledge of psychology is sorely deficient, having one's skills
go unrecognized (except for perhaps one's knowledge of testing), feeling
like "guests" in psychiatry's house. Administrative issues may also impair
one's sense of professionalism. In this regard, nearly half (48%) of
therapists working at institutional settings feel, at least to a moderate
extent ("4" on a 7-point intensity scale) that they have been frustrated by
administrative red-tape in their efforts to help patients. In addition,
59.7% feel to at least a moderate extent that they have been frustrated by
budgeting considerations in their efforts to help patients, and the identical
percentage feel at least to a moderate extent "disheartened" by the
working conditions at their setting. In short, in institutional settings,
therapists have less control over their practicesmany have excessive
caseloads or caseloads replete with difficult patients, and virtually all
must cope with the vagaries of organizational politics.
Inexperienced therapists are simply less prepared to deal with the
inevitable stresses of therapeutic work, for example dealing with acting
out patients or working through their own countertransferential
difficulties. For better perhaps, but also for worse, they have not yet
learned to leave their work at work. Interview data suggest that they
continue to concern themselves with their patients after sessions, that
they experience difficulty in acclimating themselves to the different rules
and assumptions that govern social relations, and that they are more likely
6
Therapist Burnout
to bring home leftover feelings of frustration, anger, or bewilderment.
And many inexperienced therapists have not yet adapted entirely to the
nonreciprocal nature of the work, understanding intellectually this aspect
of the therapeutic relationship but nonetheless feeling a lack of gratitude
or appeciation. Finally, fcr somewhat understandable, if not entire
defensible reasons, it is the inexperienced therapists who, in
instiututional settings, are more likely to be assigned more difficult
patients, i.e., those who the more experienced, permanert staff would
prefer not to tre E.
What prevents most therapists from burning out? For most
therapists, the greatest satisfaction lies in helping people change.
Coupled with a sense of what might be called "intimate involvement"--of
being privy to personal, profound thoughts and feelings of another--
therapists are often in a unique position of helpful intimacy. Therapists
are compensated for the stresses of therapeutic work by other factors as
well, notably that therapeutic work promotes growth in oneself as well as
others, that it affords an opportunity for most therapists to utilize and gei
paid for an ability they enjoy and feel confident about, and that
psychotherapy is a high-status, professional career with somewhat of a
mystique surrounding it. The stresses of therapeutic work may also be
buffered by rewarding contact with one's colleagues. At least among
clinical psychologists, nearly 70% feel (to a moderate extent or more) that
they have a network of professional associatesto call upon for support;
only 3% feel this not at all to be the case.
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7
Therapist Burnout
Types of Burnout
In general, burnout is caused when workers' exporience a significant
discrepancy between their input and expected output, between efforts and
rewards. Burnout is most often the consequence of feeling
inoonsequenlal. The typical symptoms of professional burnout include
feelings of ph, jcal and emotional depletion; increased irritability,
anxiety, and/cr sadness; and the development of negative attitudes toward
oneself clients, and work in general. In addition, burnout may lead to
psychosomatic symptoms (for example, insomnia, ulcers, headaches,
hypertension), alchohol or substance abuse, and increased family and social
conflicts. In therapists, burnout may mean caring less about patients and
giving less to them, feeling more easily frustrated by patients' resistances
or lack of progress, losing confidence in ono's skills or feeling
disillusioned about the healing powers of the field itself, being less
involved in or cynical about professional developmer', regretting the
decision to enter the field, or fantasizing about leaving the profession.
This is the general picture of a burned out therapist, but there
seems to be much variability in regard to both the process and nature of
this disorder. In teachers, for example, three variants of burnout have
been identified (Farber, in press): those who in response to frustration
work even harder in an attempt to produce the results they expect; those
who in response to frustration give up entirely and appear "worn out"; and
those who are relatively immune to frustration- -who neither work harder
nor give up but instead perform their work perfunctorily, having lost
8
Therapist Burnout
interest in work they now find unchallenging and unstimulating.
The first group, those frenetic individuals who refuse to acknowledge
failure until they have been completely exhausted by their efforts, were
first and most completely described by Herb Freudenberger. These are
people, said Freudenberger (1980), who have "pushed themselves too hard
for too lung, who have "started out with great (expectations and refused to
compromise along tho way" (p. 12) whose "inner resources [have been]
consumed as if by fire, leaving a great emptiness inside" (p. m(). These
individals risk their physical health and neglect their personal lives iJ
maximize the probability of professional success. For them, the
acknowledgement of failure is nearly impossible inasmuch as it reflects
on their personal worth as human beings. The job is an ex:ansion of 'heir
selves, their egos, and must be successfully performed. The second group
of burned out individuals, however, are not consumed by this degree of
passion; these "worn out" individuals are simply not as personally invested
in their work. Obsta:les to effectivework, therefore, are seen as
oppressive by these individuals and tend to dampen (rather than heighten)
their motivation. The third type of burned out individual is neither fired up
by unwanted obstacles, nor weighted .down and overwhelmed by them.
Obstacles are treated nonchalantly, worked around--the attitude in these
cases is that "there's a job to do and I'll do it reasonably well,but I won't
go out of my way to do it particularly well because the job isn't
sufficiently engaging or interesting."
The enumeration of several discrete types of burnout may be useful in
1 6
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Therapist Burnout
providing some degree of specificity to a disoroer that has to often been
described in rather general, all-purpose terms. On the other hand, as we
well know, individuals often defy easy categorization. Thus, in terms of
burnout, some, perhaps many, human service professionals vacillate among
these three types--at times feeling so energetic and optimistic that they
invest more than ever and more than is healthy in their work (frenetic
burnout), at times feeling so overwhelmed aAd pessimistic that they cut
back on their involvement (worn-out) ,and at times simply feeling
uninterested in and unstimulated by the problems and issues of their
profession. With this caveat in mind, it may be useful to construct
profiles of three different types of burned out osychotherapists.
Interviews with therapists suggest that the most likely candidate for
the first type of burnout--frenetic overinvolvement--is a young, highly
idealistic therapist either currently in a training program ur recently
graduated. Imbued with more than a healthy degree of narcisissm, such an
individual may become overly invested in curing either a specific pat'snt
or his or her entire caseload. This individual may, for example, get hooked
into the role of idealized savior for a borderline patient, or as the
nurturant, healing parent that a neglected child has never had. In the
movies (for example, Sybil, Ordinary People, David and Lisa), the
investment in such cases invariably pays off. In "real life", of course,
borderline patients don't get better so easily and autistic, schizophenic, or
abused children are rarely, if ever, cured by once or twice a week doses of
play therapy. The young therapist, therefore, who devotes him or herself
1i
10
Therapist Burnout
to "curing" such individuals, who spends countless hour: digging through
files, reading pertinent case histories, searching his or her own psyche for
creative interpretations and explanations, imagining fame and fortune as a
result of a brilliant intervention, may, indeed, ultimately become
disillusioned, even burned out, by the lack of progress so frequently
encountered in these most difficult cases. Clinical lore recognizes the
potential of this scenario by advising even the most inexperienced young
therapists against taking on but one case.
The second type, that of the worn-out therapist, seems to be most
often manifest among more experienced individuals working in institutions
with particularly oppressive bureaucractic structures. These individuals
have been worn down by organizational politics, by seemingly petty rules
and demands, by low pay and low autonomy, and by often excessive
workloads. Interviews suggest that social workers and psychologists,
rather than psychiatrists, are more prone toward this type of burnout. For
these therapists, the setting in which work occurs seems to obliterate
much of the joy of the work itself--too much work, often with too many
difficult patients, in settings offering little opportunity for advancement
or recognition. We've all seen such therapists in large state or
Veterans-administration hospitals.
Lastly, there is the underchallenged, understimulated therapist. Here
the classic examples include the psychiatrist whose day is spent
prescribing or injecting psychotropic medications, the psychologist who
day in and day out prepares or supervises behavioral contracts for
12
11
Therapist Burnout
residents of group homes, the social worker whoseonly job in the
organization is to do intakes on alcoholic patients, the therapist who has
been pigeonholed by referral sources as the one willing work with
homebound agoraphobics--in short, individualswhose range of talents are
insufficently recognized or exercised in theirprofessional settings. Here
the stresses of work are not great but neither are the rewards- -
particularly those of a psychological nature.
Some individuals, of course, may appear to be a conglomeration of all
three types; some may manifest symptoms radically different from any of
these types. What is common to the experience of burnout is simply one
factor- -the felt discrepancy between what one puts into the job ar .the
rewards one takes out.
Tr:nds
Althou,p, as noted above, burnout seems to be relatively uncommon in
our field, several trends may ba seen as potentially increasing the risk.
One is the trend toward HMOS where more bureaucracy and less
autonomy for therapists are the general rules. If a greater percentage of
therapeutic work is performed in HMOS over the next years--which seems
likely at this point--the number of wornout and underchallenged therapists
may well increase.
Another apparent trend is the increasing number of individuals with
character disorders that are presenting for treatment. As is well
documented, individuals with borderlineor narcissistic disturbances, or
those with aduictions to alcohol or other urugs, are quite difficult to treat.
12
Therapist Burnout
These patients are particularly likelyto engender frustrations, raise
expectations, and provoke fantasies of grandeur andomnipotence.
Depending on the setting at which 2 therapist works and depending too on
his o' her expectations and style of dealing with frustration, this trend
may increase the number of frenetically burned out as well as worn out
therapists.
A final trend--though one for which there is limited supporting
data--is that psychotherapy seems to becoming more a "business" than
ever. At least in some individuals an original calling to help others has
been diluted, if not entirely replaced, with a new calling to make
ever-increasing amounts of money. Of course, there's the reality of
inflation, and the need to pay off higher mortgages, but all of us know too
individuals in this field whose priorities seem to have been lost--for
whom there seem to be no limits on the number of patients to be seen or
fees charged, for whom time spent with family or on their own
recreational activities is time spend reluctantly. For these therapists,
success is primarily measured by dollars rather thin by individuals helped.
"TV.ert- lc, iNc ,44ver,
-.9f-eettreert4iere% a middle ground, and skews% psychotherapy is,
whatever else it may be, also a business. But forthose who have lost sight
of their original motivation--presumably helping others--the endless,
frantic pursuit of money may lead to a burned out state if the expected
reward (i.e., affluence or financial security) fails to occur.
The true impact of these putative trends remains to be assessed by
future research. What is heartening, though, is that current studies (e.g.,
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Therapist Burnout
Farber, 1985) indicate that the vast majority of therapists still view
"helping others" as the primary source cf satisfaction; morever, these
studies suggest that most therapists seem not to be burned out from their
work at all but rather gratified and fulfilled by it.
References
Farber, B.A. (1984). Teacher burnout: Assumptions, myths, and issues_
Teachers College Record. 86, 321-338.
Farber, B.A. (1985). Clinical psychologists' perceptions of
psychotherapeutic work. The Clinical Psychologist. 38, 10-13.
Farber, B.A. (in press). Sims and burnout in Americanleachers: Two
decades of blaming the helper. San Francisco: Jossey-Bass.
Farber, B.A., & Heifetz, L.J. (1982). The process and dimensions of burnout
in psychotherapists. Professional Psyrehology,ja, LJ3-301.
Freudenberger, H. (1980). Burn out. NY: Bantam.
Maslach, C., & Jackson, S.E. (1981). Burnout Research
Edition Manual. Palo Alto, CA: Consulting Psychologists Press, Inc.
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