Job Burnout Among Psychotherapists: A Literature Review

Introduction

Job burnout is defined as a continuous response to chronic interpersonal and emotional job stresses (Maslach et al., 2001). According to Maslach and colleagues (2001), there are three dimensions to burnout on the job: emotional exhaustion, depersonalization, and personal accomplishment or inefficacy. Emotional exhaustion is the individual stress experienced during burnout, when one’s emotional and physical resources are depleted. Depersonalization is interpersonal stress that causes disengaged responses to the job, while inefficacy is the feeling of personal incompetence during work. Overall, burnout has many negative effects on the worker, including lower productivity, reduced commitment, symptoms of prolonged stress, and mental dysfunction (Maslach et al., 2001).

Burnout occurs within many professions, prominently in teaching and social service related job sectors. Maslach et al. (2001) also explains that most research on burnout focuses on human services, education, and other jobs involving the emotional challenges that accompany caregiving roles. Psychotherapy is the practice of talk therapy aimed to help patients control and prevent symptoms of mental illness and thus eventually recover. Psychotherapists must be able to sympathize with their patients, yet remain distant to prevent emotional exhaustion. Thus, a career in psychotherapy has a high probability for burnout because psychotherapists actively engage in their highly emotional relationships with patients and continuously exhibit a caring role during their therapy sessions.

In a psychotherapist’s career, they will experience many feelings of success and failure, which may contribute to changes in feelings of efficacy and burnout. In a study done by Orlinsky et al. (1999), nearly 3,800 therapists were surveyed about their career development and experiences on the job. There was a large degree of variation in terms of work hours per week, but the average was around 20 hours per week. More than half of the participants found that they changed overall, with a higher percentage believing that the change meant progress. Furthermore, only a small percentage reported high levels of disillusionment or loss of empathic responsiveness (Orlinsky et al., 2001). Many psychotherapists will thus experience some form of development during their career, which may incorporate aspects or experiences of burnout. Throughout their job, a psychotherapist will experience changes in workload, environment, including stress and support, as well as changes in their mentality. These changes, as well as the therapist’s ability to adapt to them, correlate with their levels of emotional exhaustion, depersonalization, personal accomplishment, and thus burnout.

Multiple studies involving psychotherapist surveying indicate that psychotherapist burnout is correlated to both extrinsic and intrinsic factors alike, such as the structure of the institution, the case of the patient, external stresses, feelings of personal accomplishment, and overinvolvement. Burnout affects the quality of work of psychotherapists, indicating the importance of implementing coping strategies specifically tailored towards psychotherapists, which is to progress the overall quality of therapeutic services and thus improve society.

External Factors

External factors, which refer to environmental factors, that have been found to have the largest correlation and impact on psychotherapy burnout include the type of institution the therapist works in, the therapy topic assigned to the therapist, the type of client, stresses from work and home, as well as the amount of support therapists receive.

Public and Private Institutions

The work environment of the psychotherapist is highly correlated to the levels of burnout they experience. There are two prominent types of therapy institutions. Private institutions often refer to private practices and self-employment. Psychotherapists who work in private institutions often have more freedom in scheduling and client preference. Conversely, public sectors typically follow a bureaucratic structure and are nearly synonymous with the environment of an agency as opposed to a free form self-run clinic.

Compared with public agencies, psychotherapists working in private clinics experience less burnout. Those who work in private institutions experience less emotional exhaustion, less depersonalization, and more personal accomplishment than therapists working in public sectors (Ackerley et al., 1988). Therapists working in private sectors are often older, earn higher incomes, and work more hours per week in direct services. They spend more time in individual therapy and often work with more cases involving interpersonal growth (Ackerley et al., 1988). These differences may increase feelings of efficacy and thus decrease vulnerability to burnout. This study explains that therapists who work in private sectors do not experience as much burnout compared to those working in public institutions.

On the other hand, those working in public clinics that often have bureaucratic structures experience more burnout. Raquepaw and Miller (1989) published their findings, which showed that therapists who worked in agency settings experienced a higher level of burnout compared to their counterparts who work in private practices. Unlike those working in private sectors, many therapists encounter a different set of clients in public institutions, which may include “chronic, resistant, or seemingly untreatable patients” (Farber, 1988, p. 6). This increases feelings of inefficacy which, in turn, contributes to higher levels of burnout. Therefore, the type of environment a psychotherapist works in has an indirect correlation to levels of burnout because of its large significance in relation to clientele and therapy topics. Specifically, public institutions are often exposed to more difficult and resistant clients while private sectors admit clients mostly dealing with self-actualization issues; which impacts the levels of efficacy and thus levels of burnout the psychotherapist experiences.

Topic of Therapy and Clientele

In addition to a therapist’s work environment, the type of therapy is also an external factor that is associated with levels of psychotherapy burnout a therapist experiences. Psychotherapists who see more clients dealing with medical and health issues, sexual abuse and rape, and sexual dysfunction issues tend to have higher levels of emotional exhaustion, whereas those dealing with clients who are seeking self-actualization and interpersonal growth experience significantly less emotional exhaustion, implying a plausible correlation between case type and levels of burnout (Ackerley et al., 1988). Thus, the topic of the therapy session correlates with the therapist’s feelings of burnout.

Similarly, clients who have issues that are difficult to treat often induce higher levels of inefficacy in therapists and thus increase levels of burnout. Therapists who manage clients that are very distressed or have chronic or complex issues, among other factors, experience higher levels of stress (Simpson et al., 2018). Similarly, Farber (1988) explained that patients with schizophrenia, borderline personality disorder, or who were abused as children, for example, could rarely be treated with only weekly sessions of therapy. Especially in the case of overinvolved therapists, who may feel the need to solve all the patients’ problems, this may cause high levels of stress and feelings of inefficacy and eventually raise levels of burnout. Farber (1988) also continued to estimate that there were trends indicating an increased rate of burnout among psychotherapists, stating that the trend of an increased number of clients seeking help with character disorders may contribute to the increased levels of burnout experienced. Taken together, research suggests that levels of burnout may be correlated with the case and client type the psychotherapist works with. In other words, cases involving character disorders and traumatic experiences or clients who are disengaged may raise higher stress and inefficacy levels due to the difficulty and professionalism required by the therapists as opposed to the lesser difficulty involved with interpersonal growth cases.

External Stress and Support

Not only do the environmental factors occurring at work influence levels of burnout, the environments outside of work have lasting impacts on levels of burnout as well. Stress occurring at home lowers therapists’ threshold for coping with therapeutic frustration, which then leads to increased vulnerability to feelings of burnout (Farber & Heifetz, 1982). Furthermore, many therapists find the role of support systems to be essential in reducing anxiety and reestablishing hope. Some support systems include the implementation of supervisor relationships, support from colleagues, and activity outlets, such as participating in hobbies (Farber & Heifetz, 1982). Overall, both the stress and support found outside of the therapist’s work environment can contribute to raising and lowering levels of burnout. Family or home stress can reduce therapists’ coping threshold, while support from colleagues and supervisors, or even participation in activities significantly reduces stress and relieves tension, which contributes to lowering levels of burnout. Changes in amounts of support and stress received by the therapist, both during work and outside of work, has a large correlation to the amount of burnout they experience.

Internal Factors

While there are multiple strong external factors correlating to burnout, there are many internal factors as well. These factors rely on the therapist’s own mindset and include personal perception of work success, levels of involvement, personal background, and coping methods.

Perceived Therapeutic Success

One of the most significant factors that are related to psychotherapy burnout is the therapist’s own perceived work success. In Farber and Heifetz’s study (1982), most therapists stated that a lack of therapeutic success was the most stressful aspect of their work. Therapeutic success is defined mostly as helping patients change, having an increased understanding of human behaviour, or having a sense of intimate involvement with patients (Farber & Heifetz, 1982). In short, feelings of therapeutic success are positively associated with feelings of efficacy, which are negatively related to burnout.

Levels of Involvement

Another important internal factor that is correlated to psychotherapist burnout is the levels of involvement the therapist exhibits in their cases. Overinvolvement often describes the instance in which a psychotherapist takes their feelings, thoughts, and psychotherapy work into other aspects of their life. Overinvolvement is correlated positively to emotional exhaustion and depersonalization (Ackerley et al., 1988). Thus, an optimal level of involvement can reduce feelings of burnout while higher or lower levels can increase it.

The different levels of involvement within psychotherapists may be grouped into psychotherapist profiles. In Farber’s comprehensive study (1988), he listed three profiles of psychotherapists most likely to experience burnout: the young and highly optimistic therapist, the worn out therapist, and the underchallenged and understimulated therapist. The first profile, the young and enthusiastic therapist, is typically “imbued with more than a healthy degree of narcissism” (Farber, 1988, p.11). They may highly invest themselves in their patients’ cases, to the degree in which they believe to be the patient’s idealized saviour. The worn out candidate is found mostly in therapists working with institutions. The setting of their work may cause the psychotherapist to be underinvolved with their work. Similarly, the understimulated therapist experiences a lack of recognition or work, causing them to be uninvolved with their job (Farber, 1988). It can thus be seen that burnout has high correlations with levels of involvement, as seen by Farber’s psychotherapist burnout profiling. Both extremely high and low levels of involvement can correlate with high levels of burnout.

Personal Background and Coping Methods

Intrapersonal factors may play a role in therapist’s susceptibility to burnout. In fact, some research suggests that a significant proportion of therapists may have entered the industry because of their own histories (Simpson et al., 2018). Early maladaptive schemas (EMS), which are “self-defeating core beliefs, themes or patterns that we repeat throughout our lives, which result from unmet needs during childhood” (Simpson et al., 2018, p.8), is identified within mental health professionals. Unrelenting standards and self-sacrifice are two of the most common EMS among psychologists and abandonment, mistrust/abuse, and emotional inhibition are the EMS most predictive of emotional exhaustion (Simpson et al., 2018). This study suggests that there is a correlation between personal histories and susceptibility to burnout.

Similarly, the coping methods of the therapist, another intrapersonal factor, may also increase the therapist’s vulnerability to burnout. Burnout can be understood by both analyzing the EMS that are active and how the therapist copes with those EMS (Simpson et al., 2018). The detached self-soother, who may, for example, cope by overeating and using alcohol, and the detached protector, who will close off their emotions, were the two most common coping methods among therapists in the Simpson et al. (2018) study. These coping strategies are positively correlated with emotional exhaustion and thus with psychotherapy burnout.

Discussion

Previous research has shed light on the many factors that are correlated with psychotherapist burnout, which include both external factors (i.e., factors that are related to the environment) and internal factors (i.e., factors that are related to the experiences and mindset of the therapist). There are also many factors that are not correlated to burnout. Understanding the factors that are correlated to burnout is important because burnout among psychotherapists can largely affect their quality of work. Psychotherapists play a significant role in a society, as their services can allow for the entirety of society to advance and grow. Thus, understanding and potentially finding treatments for psychotherapist burnout can improve psychotherapists’ work quality and therefore help with the betterment of society.

Non-Factors

All the aforementioned studies have not only concluded that similar external factors and internal factors were correlated to psychotherapy burnout, but they have also mentioned multiple factors that showed no correlation to burnout. Specifically, the age, gender, race, marital status, educational level, theoretical orientation, caseload, and number of clients of a psychotherapist have no correlation to levels of burnout. In short, multiple studies have concluded that there are many factors that have no correlation to burnout, prominently the basic demographic differences of psychotherapists, their theoretical orientation, and actual caseload amount.

Interestingly, the perceived caseload, rather than actual caseload, is correlated with burnout. According to Raquepaw and Miller (1989), non-factors such as caseload and number of clients are correlated with burnout only when there is a perception of large caseloads or numbers of clients. In other words, the actual number of cases or clients has no correlation to burnout levels, but the psychotherapist’s personal belief that they have a large number of either does (Raquepaw & Miller, 1989). This study explains the importance that perception has in relation to burnout, as potential coping strategies can aim to change the therapist’s thought patterns to reduce burnout caused by these perceptions.

Potential Coping Strategies

Short term intervention services can potentially reduce burnout among psychotherapists. Research by Isaksson et al. (2008) monitored 185 Norwegian doctors for a one year cohort study. They discovered the effective impact short-term intervention programs had on the doctors. The participants attended short-term counselling interventions. Some had a single day 6–7 hour session involving activities such as describing situations while a counsellor investigated sources of identity, self esteem, and self reliance, as well as identified present coping strategies. Others attended a week-long course with a daily 90 minute lecture about topics such as working life, identity, resources, and preventions, as well as 90 minute group discussions that allowed patients to share experiences and do physical activity. After a one-year follow up, the participants had reduced burnout and emotional exhaustion, evident by reduced working hours, reduced full-time sick leave, and increased psychotherapy participation (Isaksson et al., 2008). Thus, having occasional intervention programs may significantly reduce levels of burnout within doctors in the long term, and can be a potential program that may reduce burnout among psychotherapists.

Other potential coping strategies can also be implemented in the psychotherapy field. For example, having specialized counsellors who may focus solely on psychotherapist clients. These specialized counsellors should have a much lower frequency of therapy sessions than regular psychotherapists to prevent further burnout. They should also receive training that involves thinking mechanisms or coping strategies to reduce self-deprecation, negative thoughts, and stress. These specifications may allow for counsellors to experience less burnout while helping their psychotherapist clients. Reciprocal counselling, in which colleagues are assigned the role of counsellors for each other, is another strategy that may be effective. Changes within the institution system, such as elevating the levels of support within the workplace (especially among supervisors and higher-position individuals), training psychotherapists to have personal coping mechanisms and thinking strategies, and allowing more freedom for psychotherapists to implement their own schedules and state their preferences for clients and cases can also reduce levels of psychotherapist burnout. Overall, it is important to understand the factors that are correlated with psychotherapy burnout in order to implement effective, systematic coping strategies and interventions.

Implications

This literature review sheds light on the multiple external and internal factors that correlate to psychotherapy burnout. With a greater understanding of the factors correlating to psychotherapy burnout, there is a greater understanding of strategies to reduce it.

Therapists positively contribute to the overall psyche and wellbeing of a population as well as mitigate chances of the dangers mental illnesses may have on individuals and society. In extreme, but not uncommon, cases, mental illnesses such as depression may lead to suicide. Additionally, during or as a result of therapy, individuals who achieve self-actualization and personal growth may contribute to the growth of a society as a whole. Without the work of psychotherapists, there would be many individuals suffering from mental health issues without having any professional help to seek.

The impacts of therapist burnout can greatly affect the quality of work the therapists produce. Especially because of the importance therapists have on society, psychotherapist burnout may have a severe and wide extent of consequences. The decreased quality of work that results from psychotherapist burnout may thus cause increased depression rates or prevent individuals from achieving personal growth. The role of psychotherapists is very important and relevant to the wellbeing of society, which is why a deep understanding of factors correlating to psychotherapy burnout, and ways to mitigate it, is significant.

References

Ackerley, G. D., Burnell, J., Holder, D. C., & Kurdek, L. A. (1988). Burnout among licensed psychologists. Professional Psychology: Research and Practice, 19(6), 624–631. https://doi.org/10.1037/0735-7028.19.6.624

Cook, J. M., Biyanova, T., Elhai, J., Schnurr, P. P., & Coyne, J. C. (2010). What do psychotherapists really do in practice? An Internet study of over 2,000 practitioners. Psychotherapy: Theory, Research, Practice, Training, 47(2), 260–267. https://doi.org/10.1037/a0019788

Farber, B. A., & Heifetz, L. J. (1982). The process and dimensions of burnout in psychotherapists. Professional Psychology, 13(2), 293–301. https://doi.org/10.1037/0735-7028.13.2.293

Farber, B. A. (1990) Burnout in Psychotherapists: Incidence, Types, and Trends. Psychotherapists in Private Practice, 8(1), 35–44, https://doi.org/10.1300/J294v08n01_07

Ford, E. S. C. (1963). Being and Becoming a Psychotherapist: The Search for Identity. The American Journal of Psychotherapy, 17(3), 472–482. https://doi.org/10.1176/appi.psychotherapy.1963.17.3.472

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job Burnout. Annual Review of Psychology, 52, 397–422. https://doi.org/10.1146/annurev.psych.52.1.397

Orlinsky, D. E., Rønnestad, M. H., Gerin, P., Davis, J. D., Ambühl, H., Davis, M. L., Dazord, A., Willutzki, U., Aapro, N., Botermans, J.-F., & Schröder, T. A. (2005). The Development of Psychotherapists. In D. E. Orlinsky, M. H. Rønnestad, & Collaborative Research Network of the Society for Psychotherapy Research, How psychotherapists develop: A study of therapeutic work and professional growth (pp. 3–13). American Psychological Association. https://doi.org/10.1037/11157-001

Raquepaw, J. M., & Miller, R. S. (1989). Psychotherapist burnout: A componential analysis. Professional Psychology: Research and Practice, 20(1), 32–36. https://doi.org/10.1037/0735-7028.20.1.32

Simpson, S., Simionato, G., Smout, M., van Vreeswijk, M. F., Hayes, C., Sougleris, C., & Reid, C. (2018). Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors. Clinical Psychology & Psychotherapy, 26(1), 36–46. https://doi.org/10.1002/cpp.2328

Isaksson, K. E., Gude, T., Tyssen, R., & Aasland, O. G. (2008). Counselling for burnout in Norwegian doctors: one year cohort study. BMJ, 337(7679), 1146–1149. https://doi.org/10.1136/bmj.a2004