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For many, the decision to provide clinical care to people living with HIV and AIDS constitutes an intellectually rich and emotionally satisfying career choice. And yet, even in the era of highly active antiretroviral therapy (HAART), which has extended survival and engendered the hope of converting HIV to a chronic but manageable disease for all who are infected, work in this field is fraught with multiple stressors that may induce provider burnout.
Does This Sound Like You?
[B]urnout syndrome has been most consistently described as a multidimensional process with 3 central constructs: emotional exhaustion (feeling emotionally drained and exhausted by one's work), depersonalization (negative or very detached feelings toward clients ...), and reduced personal accomplishment (evaluating oneself negatively and feeling unsatisfied with positive job performance and achievements). ... The most fundamental tenet of burnout syndrome is that it is an end-stage consequence of a process of deterioration in a person who has been exposed to relentless stress in the work environment. (Demmer, 2004, p. 523)
It is no surprise, then, that "[b]urnout has been related consistently and negatively to health, work performance, job satisfaction, quality of life and psychological well-being" (Rabin, Feldman, & Kaplan, 1999, p. 160).
Who is at risk for burnout? According to Demmer, a variety of factors are associated with a greater likelihood of burnout in providers of HIV care. These include "younger" age (with burnout perhaps related to a lack of HIV work experience and/or overinvolvement with clients); anxiety and/or depression; low "hardiness" levels (i.e., feeling and acting alienated, helpless, and insecure); a high external locus of control (i.e., believing that events occur as a result of fate, luck, or chance); external coping strategies (i.e., denying, avoiding, or passively accepting work-related stressors); fear of contagion; negative attitudes toward clients (due to work role dissatisfaction and/or work overload); the perception that HIV work is difficult; problematic relationships with colleagues, supervisors, or higher-level administrators; and inadequate support from friends and family around the choice to work in the HIV field.
From the HAART
During "the dark years" of the pandemic (up to the mid-1990s), many health care workers experienced demoralization, despair, and frustration as they cared for their patients. ... Research identified the following stressors of HIV/AIDS caregiving during the years before the advent of HAART: the clinical manifestation of HIV/AIDS and the course of the illness, ... risk of contagion, ... high mortality rate among patients, ... dealing with such issues as homosexuality and drug addiction, ... ethical concerns about confidentiality and decisions regarding treatment, ... stigma associated with the disease, ... and inadequate support. ... Coping with ongoing loss was a primary stressor for HIV/AIDS health care workers. ... They constantly had to witness patients endure pain, disability, and death. ... Watching while young people died in the prime of life imposed a heavy emotional burden. (Demmer, 2004, p. 528)
While a number of these stressors continue in the HAART era (e.g., work overload; contentious relationships with colleagues, supervisors, and administrators; paperwork demands; low levels of monetary compensation in AIDS service organizations; HIV stigma), new stressors have emerged in the context of improved treatment. According to Demmer, these include:
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Uncertainty – Just as people living with HIV struggle to balance optimism regarding the benefits of HAART with the management of side effects and questions regarding HAART's long-term efficacy, so too do their providers.
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Shift from "hero" to provider of routine care – While clinicians in the pre-HAART era developed intense relationships with clients and concentrated their efforts on providing physical and emotional comfort to those who were preparing to die, HIV care today may be experienced as less "interesting" and/or exert less of a pull for personal involvement on the part of providers.
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Antiretroviral adherence issues – If death was the central focus of care in the pre-HAART era, adherence has assumed preeminence with the emergence of concerns about the development of antiretroviral resistance.
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Resumption of risky sexual behaviors among clients – Improved health and the perception among some that HAART has made HIV less of a threat have intensified the need to focus on secondary HIV prevention (i.e., "prevention for positives") in the context of clinical care.
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Death of clients – Although people are living longer with HIV, deaths continue to occur from AIDS-defining conditions, challenging newer clinicians, who may feel unprepared for a client's death, as well as veteran providers, for whom recent deaths may tap into unresolved grief from the pre-HAART era.
Upping the Ante
Mental health professionals offering HIV-related psychotherapy must contend not only with the stresses inherent in HIV care, but also the stresses particular to the work of the psychotherapist. "While psychotherapy can be rewarding, it is often demanding and lonely, filled with excessive expectations and a lack of gratification. This can obviously lead to stress and subsequent burnout. Dealing with the emotional suffering of others, both patients and families, also has its effects on the psychotherapist. This leads to 'compassion-fatigue', depletion of emotional resources and subsequent burnout" (Rabin, Feldman, & Kaplan, 1999, p. 163).
Seven Salutary Suggestions
Interventions to reduce workplace stress and prevent burnout are generally pitched at the systems (organizational) level and/or the level of the individual mental health practitioner.
With regard to the latter, Osborn (2004) offers a novel perspective by shifting "from a problem, deficit, and pathology focus (i.e., 'burnout prevention') to a growth, mastery, and salutary orientation (i.e., 'stamina promotion') ..." (p. 321) in framing interventions initiated by and for the care of the individual mental health provider. This health-oriented perspective on professional longevity centers on helping the clinician to maintain stamina in the work.
What does she mean by stamina? "A discussion of stamina [draws] attention to the cultivation, amplification, and routine use of one's strengths and resources, as opposed to focusing on a problem (i.e., burnout) and outlining attempts to rid oneself of or continually fight against the problem (i.e., coping) ... [and so shifts] attention away from notions of stress and depletion. It focuses instead on cultivating resources intended to keep one's outlook positive and one's work fresh, relevant, and rewarding" (p. 319).
Osborn presents seven components of stamina that take the form of a mnemonic, with each component corresponding to one of the seven letters in the word STAMINA. While not exhaustive, her listing includes:
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Selectivity – "Selectivity refers to the practice of intentional choice and focus in daily activities and long-term endeavors. It means setting limits on what one can and cannot do and, in the process, being deliberate in one's tasks and purposeful in one's mission" (p. 322). In practice, selectivity involves the development of reasonable appointment schedules and realistic, individualized treatment plans. It also involves projecting a clear professional identity with regard to therapeutic posture, the scope of practice, and areas of professional expertise.
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Temporal Sensitivity – Mental health professionals "must be constantly aware of the given restrictions and limitations of time – in sessions with clients, in determining the appropriate length of overall treatment, and in the spacing of sessions – and make the best use of the time allotted" (p. 322). "[T]emporal sensitivity implies that time is not only something to be managed or manipulated well (e.g., working within deadlines, arriving to and ending ... sessions 'on time'), but also something that is viewed realistically and respectfully" (p. 322). Osborn suggests that "[a]cknowledging the limitations of time fosters an appreciation for and a focus on the present moment, which may imply effective and meaningful ... practice" (p. 323).
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Accountability – "[A]ccountability ... refers in part to being able to practice according to a justifiable, ethical, theoretically guided, and research-informed defense – one that has merit and makes sense not only to ... clients or the [clinician] him- or herself, but also to the group of professionals of which the [clinician] is a part. ... [A]ccountability – and credibility – refers to respecting and working within professional guidelines (e.g., standards of care ...) [and] generates stamina when the [clinician] takes responsibility for ... his or her clinical decisions and actions. This [reflects] an internal locus of control, which [has been] found [to be] related to higher job satisfaction, ... less burnout, and less perceived conflict on the job among social workers and case managers" (p. 323). Accountability is evident when a clinician invites feedback about his or her clinical work, participates actively in professional associations and continuing education opportunities, and keeps tabs on the professional research literature, since accountability "involves openness to innovation and a consideration of multiple perspectives" (p. 323).
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Measurement and Management – "[T]his ingredient of ... stamina stipulates that the [clinician] makes conscientious, careful and ongoing efforts to conserve and protect those resources he or she values" (pp. 323-324). Included in these resources are time, material possessions (e.g., books), conditions (e.g., rewarding work, ethical boundaries), personal characteristics (e.g., thoughtfulness, hopefulness, assertiveness), and energies (both monetary and intellectual). "[P]sychological stress occurs when these resources are threatened or lost, or when investments are made that do not reap the anticipated level of return. The result may be analogous to emotional exhaustion, one of the three dimensions of burnout ... . Protecting and conserving the resources of one's energy, time, and compassion, for example, may therefore attenuate psychological stress, prevent burnout, and contribute to ... stamina" (p. 324). Practically, the cultivation and preservation of resources are facilitated through regular consultation with at least one trusted colleague, bringing supportive people into one's life, and participating in enriching, personally satisfying activities and relationships, which might include the pursuit of one's own psychotherapy.
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Inquisitiveness – "Cultivating and sustaining stamina ... involves ... a 'disposition of wonder or curiosity' ... about human behavior and the unique experiences of individuals, a fascination that may have represented the early or initial appeal of becoming a helping professional. Without a posture of intrigue or regard for the therapeutic process as one of 'mutual puzzling' ..., [clinicians] may be vulnerable to burnout" (p. 324). Inquisitive clinicians honor the individuality of each client, consider a diagnosis what one has and not who one is, and suspend judgment to become a student of the client's experiences. In fact, inquisitiveness fuels stamina when the clinician "assum[es] the posture of a student in all areas of ... practice, continually intrigued by and learning from clients, colleagues, [the] profession, and him- or herself" (p. 325). Such openness is reflected in continual study of developments in psychotherapy, ongoing consultation regarding one's practice, and engagement in a process of self-examination.
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Negotiation – "Negotiation ... can be understood as one's ability to be flexible, to engage in give-and-take, without 'giving in.' In addition, clinical and other professional decisions and actions are purposeful (or well grounded); informed by standards of care, theory, and research; and not conducted haphazardly or arbitrarily. Understood in another way, [clinicians] need to be responsive to and cooperate with others, while simultaneously remaining steadfast to and upholding certain values, guidelines, or standards" (p. 325). "Professional[s] generate and sustain stamina by initiating and participating in processes of negotiation (with people, ideas, policies, etc.), and viewing such interactions as collaborative and coconstructive, rather than viewing themselves solely as passive recipient or 'expert'/'answer bearer'" (p. 326).
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Acknowledgment of Agency – In this instance, "agency refers to ... an intangible, dynamic force; the 'life blood' of a person; and the trait or condition whereby instrumentality (or one's purpose) is manifested" (p. 326). By acknowledging agency, clinicians recognize "and make use of the undeniably persistent strength, resourcefulness, and will of the human spirit – within him- or herself and with his or her clients" (p. 326).
Averting Burnout Administratively
Mental health administrators are in an excellent position to facilitate reductions in and management of workplace stress experienced by mental health professionals and contributing to burnout. A variety of approaches, adapted from Rabin, Feldman, and Kaplan and used separately or in combination, are offered below:
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Identify sources of stress and promote positive coping strategies in individual clinicians – While administrators are well situated to promote positive coping by intervening at the systemic level (several examples follow), they can also support mental health professionals by promoting personal resourcefulness/self-care skills. These include self-assertion, rational thought and decision-making, open communication and concern for colleagues, use of stress management techniques (e.g., meditation, relaxation methods), and encouragement of effective planning and organization (e.g., goal setting, time management, etc.).
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Peer supervision or peer consultation groups – These are leaderless groups in which mental health professionals meet on a regular basis to review cases and contemplate approaches to treatment. Members share their knowledge and expertise, collaborate with colleagues, and contribute to the professional development of their fellow clinicians.
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Balint groups – "Balint groups have an open and supportive style but are similar to peer supervision in their openness and are run by two group leaders. These groups provide health providers with a sympathetic and accepting forum to present instances of work-related interactions troubling them at a given moment. … Balint group experiences have been found to enhance professional self-worth, self-esteem, and confidence … . Primary care health providers (doctors, nurses, social workers) have benefited much from these experiences and recently these groups have been found to be effective in reducing and preventing burnout. … Integrated groups of mental and primary care providers have also been found to help the two groups collaborate more effectively" (p. 164). 1
- Support groups – These include:
o system-oriented, work-based groups composed of members from the same functional unit (e.g., a multidisciplinary treatment team);
o long-term groups composed of members with the same or related training who work in different agencies or facilities; and
o short-term groups composed of members who meet for a certain number of sessions to address a specific issue (e.g., employee victims of violence in a healthcare facility).
"The underlying focus of all these support groups should be to enhance the mental health providers' perceptions of the importance of collegial support, which has been found to diminish the level of depersonalization often experienced by staff members ..." (p. 164).
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Modifying organizational factors – "Examples are improving ... working conditions and optimizing work schedules for the benefit of ... employees, including providing a mentoring system for new professionals ..., changing the function of staff meetings into a more supportive/caring mode, and encouraging achievement of the staff. ... Social events (get-together evenings, team field trips) may also ... reduce team burnout" (pp. 164-165).
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In-service training programs – "Chronic stress and subsequent burnout can be considered a breakdown in ... a person's feelings of efficacy ... . This feeling of efficacy may be restored by their gaining greater knowledge and clinical experience as a way of reducing perceived vulnerability to the stressors of therapeutic work ..." (p. 165).
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Clinical supervision – Clinician "overinvolvement" with a client can lead to emotional exhaustion. Supervision can assist in identifying and addressing overinvolvement, with a goal of reestablishing appropriate boundaries.
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Temporary withdrawal from clinical work – "In some instances, temporary withdraw[al] ... may be a practical way of coping with burnout. Planned temporary withdrawal can quell feelings of emotional overload through physical withdrawals (e.g. reduction of contact hours with patients, work breaks or absences, vacations); psychological withdrawal (e.g. cognitive coping with ... distracting thoughts); and shifting to work tasks which do not involve direct contact with people ... . An innovative practical solution for burnout is the 'decompression routine' between leaving work and coming home. Mental health professionals can engage in some solitary activity in order to unwind, relax and take their mind off the events of the day ..." (p. 165).
References
Demmer, C. (2004). Burnout: The health care worker as survivor. AIDS Reader, 14(10), 522-523, 528-530, 535-537.
Osborn, C.J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling & Development, 82(3), 319-328.
Rabin, S., Feldman, D., & Kaplan, Z. (1999). Stress and intervention strategies in mental health professionals. British Journal of Medical Psychology, 72(Pt. 2), 159-169.
– Compiled by Abraham Feingold, Psy.D.
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1 For more information, see "'Essential' and 'desirable' characteristics of a Balint group," approved by the Council of the British Balint Society, March 1994: http://familymed.musc.edu/balint/Balintgroups.html.
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Winter 2005 Newsletter / Volume 6, Issue 2
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