In order to burn out, a person needs to have been on fire at one timeAyala Pines
COVID-19 has shone an overdue light on the indispensability of workers that we often take for granted. Nurses, doctors, social workers, taxi drivers, cashiers, cleaners and many others. Whilst many of us have had to adjust to the comparatively mild inconveniences of working from home, these workers are often putting their health at risk to deliver essential services and care. As this emergency and lockdown continues, these workers will need access to comprehensive support to stave off and manage the effects from burnout. The term burnout is most commonly used with reference to those who exert significant “emotional labour” in their work, which refers to the requirement of managing emotions and feelings whilst dealing with people (i.e patients or customers) with the term becoming ubiquitous across not just healthcare but also professional services occupations.
Burnout, more than just exhaustion
A recent definition by Christina Maslach of the University of California, who originally coined the term and Michael Leiter, currently at Deakin University, provided a concept of burnout as:
“…the index of dislocation between what people are and what they do. It represents an erosion of value, dignity, spirit and will – an erosion of the human soul. It is a malady that spreads gradually and continuously over time, pulling people into a downward spiral from which it is hard to recover.”
For Maslach and Leiter there is a dislocation of what people are and what they do, causing a split where actions no longer reflect values. This split leads to a chasm of meaningless that in turn can become a downward spiral of rumination, self-doubt and eventually depression. The dislocation means that the underlying values that supported an initial devotion or idealism have shifted or dissolved, usually as the result of some perceived or actual failure or a head-on collision with a difficult occupational reality.
What is interesting about the above is the inclusion of words such as values, spirit and soul. This definition by Maslach and Leiter alludes to the fact that burnout syndrome, cannot be viewed simply as exhaustion but as something related to existential loss of meaning and purpose. Viktor Frankl, the late psychiatrist, holocaust survivor and founder of Logotherapy could have the key to understanding why burnout is becoming more common. Frankl’s overarching philosophy of the “will to meaning” suggested that to avoid depression and existential despair, one had to authentically live out one’s underlying values by paying attention to what is meaningful. These values are not necessarily moral, but are related to a deeper sense of what attracts your attention, focus and sustained, conscious action; an integrated embodiment of an individual’s orientation toward and action within their framework of meaning.
For Frankl, he believed that the decline in spiritual and religious life, what he referred to as the noetic dimension, had led to a vacuum of meaning which had been filled by a new kind of devotion to work and it is this devotion, which can sew the seed for burnout. In research published last year by Norbert Riethof and Petr Bob, in Frontiers of Psychiatry, the initial stage of burnout actually involves very intense experiences of meaningful life and work, a kind of idealism or devotion that by the end of the burnout process has been lost following a perceived failure to live up to impossibly high expectations.
There is a counterintuitive element here, which is that burnout appears more likely to affect those that demonstrate a higher level of idealism in their work. Idealism can be a valuable trait for an individual and the organisation they work for as it motivates people to make a difference and go beyond what is asked of them. However, the resulting excitement elicited by this acute sense of meaning, can lead to excessive dedication (perfectionism), a lack of clinical or personal detachment and an obscuring of insight into the knowledge of one’s own limitations. A bright burning candle casts a long shadow and the shadow of idealism appears to be burnout.
Excitement and stress are two sides of the same coin with both of these emotions releasing the stress hormone cortisol, which the body uses to prepare for action. The secretions of these hormones build up over time and if behaviours and work practices aren’t changed, they can have a serious effect on physical and mental health leading to a potential breakdown and in the most extreme cases, suicide. In the United Kingdom a 2018 study found that the probability of doctor’s committing suicide was five times higher than the general population, with a significant factor being the pressure that doctor’s are under due to a lack of resources.
The difficulty with the term “Burnout”
The trouble with managing burnout partly comes from the difficulty in its definition and diagnosis. In a recent survey of intensive care health professionals the overall number of those categorised as suffering from burnout ranged from 3% to 40% depending on how the syndrome was defined. Part of the difficulty of “diagnosing” burnout is due to its interaction with other mental health issues like depression, begging the question, how much is the term ‘burnout’ simply a socially acceptable label for someone actually suffering from depression? Some of the key descriptions of burnout; loss of enjoyment in things you used to find enjoyable (such as work), persistent fatigue, apathy and cynicism are actually key diagnostic criteria of the American Psychological Association for major depressive disorder. In addition to this, 2017 research in the Journal of Neuroscience and Biobehavioral Reviews, found that there was no distinction between the biological markers in the brain of those diagnosed with burnout compared to those diagnosed with major depressive disorder.
The ubiquity of the term ‘burnout’ leads to a number of issues. Overdiagnosis of the syndrome leads to a perceived normalisation of this as a necessary occupational hazard, resulting in acceptance and no urgency in developing the appropriate support frameworks. This resulting lack of support can lead to declining levels of work productivity, job satisfaction, employee engagement and increasing levels of stress and depression. Finally, it appears as though using the term is becoming a euphemistic veil for what is actually depression, something which could prevent someone seeking help due to a normalisation of this as a facet of professional life.
Mindfulness training has recently received a lot of attention from researchers and organisations as a technique for reducing physical and mental stress. Mindfulness meditation, leveraging present moment awareness, can help to create space between thoughts, emotions and actions. This “space” can help to improve cognitive empathy, otherwise known as detached concern, whilst learning to manage and not get caught up in emotional empathy, or taking on the emotional states of other people (patients, customers). This awareness can also provide an insight into an individual’s limits, informing them of when to take a step back and some time out, whilst also providing a positive perspective on purpose and achievements. The practice can act as a kind of ‘reset’ of the mind, a process that un-conceals values and brings awareness of actions, allowing a restoration of meaning through integration of both.
Beyond personal practices, a broader shift in how workplace mental health is dealt with, including the communication and support for those with occupationally specific depression could also have a significant impact. A comprehensive review of burnout treatments in 2010 found that a combination of personal and group interventions provided by organisations had the largest effect on managing burnout in individuals. This was partially due to a greater level of acknowledgement about burnout and its potential as an occupational hazard, in turn providing people with support and also an implied understanding that those suffering weren’t alone in how they were feeling.
Bringing it all together
The after-effects from the strain of this crisis are likely to be felt most acutely when the lives of most of us go back to normal. The present moment is a critical opportunity for us to re-evaluate the importance of these individuals, putting in place the proper resources and support to ensure that we protect those that are under so much strain at this time. By developing the adequate support structures for those in critical care industries, organisations can reduce the number of workers lost to burnout and workplace depression, in turn maintaining continuity of standards, care and service for those that rely on them.