An Overview of Burnout and Relevant Interventions

Abstract

Burnout is a term used to describe the emotional and physical depletion that occurs after a period in which a person gives of themselves to the point of exhaustion. It has often been associated with studies involving therapist exhaustion but is also applicable to those who care for others within families, for first responders, for health service providers, and even for those who may not be involved in people work, but simply become drained from incessant job demands. Several practical interventions are presented, and these interventions are generally not of a formal psychotherapy nature. Some interventions involve structural changes in the work setting along with activities such as social engagement, yoga, meditation, exercise, etc.

1. Introduction

Burnout or burnout syndrome are terms that are used to describe the exhaustion that occurs when one becomes depleted by the unrelenting demands that are placed upon them, usually in a work setting. Herbert J. Freudenberger (1926–1999) is credited with popularizing the expressions, burnout and “burnout syndrome,” and these descriptors appear to have arisen out of his personal experience with “free clinics” that he dedicated himself to in the 1970s. According to Freudenberger the free clinic movement found its origin in Haight-Ashburn, in San Francisco to provide services to the poor, the young, for bad drug trips, venereal disease, and other medical problems [1, 2].

The clinics were free in that they did not charge a fee for services, and they were supported by the efforts of volunteers. The concept of free clinics was a philosophical divergence from traditional fee for health service offerings and was intended to support the spirit of inquiry into alternative lifestyles that was epitomized by the “hippie” culture of the day. Freudenberger’s description of the burnout syndrome arose from his personal experiences of working long hours as a psychoanalyst. He suggested that free clinic workers “Spend all the time you can spare-and some you cannot …and be prepared to work long hours for no pay.” ([2], p. 61). This ostensibly endless giving in the service of others was said to lead to “Staff Burn-out.” [2].

The idea of a “syndrome” came about when Freudenberger provided a list of both physical and psychological “signs” or symptoms that accompany burnout. The physical symptoms include fatigue and exhaustion, inability to shake a cold, sleeplessness, shortness of breath, and others. Behavioral or psychological symptoms include depression, irritability, frustration, suspiciousness, stubbornness, inflexibility, and feelings of knowing more than others in the clinic and thereby feeling indispensable. Freudenberger [3] saw “man” as an “energy system” and when the provider wishes to help in excess, this energy system becomes drained and can dry up leading to the emotional exhaustion of the burnout syndrome. He further asserted that those who are committed to and identify with their work are more likely to burn out than those who are less committed [3]. He speculated that the overly committed may be those who are attempting to deal with their own childhood adjustment difficulties by throwing themselves into work involving helping others. Their work with others becomes more than simply a job but is additionally a way of undoing their past emotional difficulties and trauma by overidentifying with the helper role. The helper or counselor is managing the pain of others but in doing so is attempting to also deal with their own emotional difficulties. It is likely that Freudenberger, having fled Nazi Germany and having lived on the streets in the United States was all too familiar with the burnout syndrome that he describes as taking place in others [4].

2. Terms closely related to burnout

One of the difficulties that is encountered when dealing with burnout is existence of other terms that appear to describe phenomena like burnout. Among these terms are secondary trauma, secondary traumatic stress disorder (STSD), vicarious trauma, compassion fatigue, and empathic strain. The various terms describe emotional stress that follows from working with others who are in distress and particularly those who have been traumatized. It might be argued that burnout can occur in work environments that don’t involve dealing with others who are in distress but could also occur in demanding work settings where one is frantically trying to stay on top of the demands being made upon them. Nevertheless, several authors consider the various terms that are like burnout to be interchangeable for the most part [5, 6].

Secondary trauma which is also referred to as secondary traumatic stress disorder (STSD) [7], and vicarious trauma describe the transfer of emotional distress from a traumatized individual to the person who is treating or dealing with that individual. The outcome of the emotional distress is referred to compassion fatigue or empathic strain. All these phenomena, i.e., STSD, secondary trauma, and vicarious trauma can, through the process of compassion fatigue or empathic strain, get to the point where the caretaker begins to become emotionally drained or burnt out. From this point of view, burnout can be conceived as an endpoint or consequence of giving oneself to the point where emotional exhaustion, cynicism, sleeplessness, irritability, and other symptoms, take place.

Again, it is important to note that burnout, unlike the other terms used in this section, can involve environments where one is not dealing with the distress or trauma of others but is rather dealing with job demands that are ultimately draining and overwhelming. However, despite what appears to be differences among the various terms, the degree to which they overlap, often results in the terms being used synonymously. For example, one research summary paper [8] on burnout defined it as “a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who ‘do people work’ of some kind” (p. 26). Here we see that the definition now entails ‘people work’ and this would imply that burnout does not occur with other kinds of work. As can be seen from this difference in points of view, there is little universal agreement on the use of term of “burnout” and other related terms. Some see it as occurring because of people work and some do not. Additionally, there is lack of empirically based differentiation among the terms based upon methodologically sound research studies. The lack of agreement among writers results in considerable confusion. Nevertheless, it is generally agreed that burnout or burnout syndrome does represent a kind of emotional and physical exhaustion [9] and depletion that results from what is perceived to be excessive demands placed upon an individual.

3. Perspectives on intervention

There has been considerable high-quality research on interventions for PTSD and primary trauma, but this is not the case for burnout or similar phenomena like secondary trauma, vicarious trauma, etc. In fact, some authors (e.g., [10]) maintain that while there are many treatments and interventions noted in the literature, that there is little evidence that one measure is any better than any other, and that no intervention has a sound empirical foundation showing it to be effective in ameliorating burnout. Despite the lack of strong empirical support and validation, it has been suggested [10] that interventions strategies should include (a) self-monitoring, (b) obtaining supervision, and (c) intervention and support of colleagues.

Self-monitoring and self-awareness are critical elements for optimal functioning in those involved in psychological treatment [11]. Self-monitoring involves careful assessment of one’s stress levels and then engaging in activities to reduce this stress. These activities could include personal psychotherapy, meditation, prayer, exercise, pleasure reading, and engaging in social activities.

Obtaining supervision is another strategy that can be implemented to manage burnout. Supervision can be sought from colleagues or from those who specialize in working with therapists on the verge of burnout. Supervisors can provide novel perspectives regarding client needs and can also help the provider to become more aware of their own needs for stress reduction. Supervision can also be provided by the organization within which the provider may provide services.

Regarding social support, “There is overwhelming evidence that social support is a hugely beneficial factor in reducing and coping with stress reactions” ([12], p. 44). Providers would do well to seek out support groups whether these groups involve healthcare professionals or not. Similarly, it is the ethical responsibility of providers to volunteer support to any colleagues who needs support. It appears that the benefits of social support are “hardwired” into us such that its absence can be painful. One need only observe the impact of solitary confinement to realize that isolation in painful and support can be of significant benefit.

4. Burnout vs PTSD interventions

There are those who have proposed that interventions for burnout, secondary trauma, STSD, vicarious trauma, etc. and those for PTSD are nearly identical [13, 14]. This position does not appear to be warranted given the nature of the different stressors in PTSD and burnout. PTSD is due to an identifiable stressor or stressors that are perceived to be far beyond what the individual is capable of managing. PTSD stressors can be life threatening events, natural disasters, debasing and demeaning experiences, assaults, car accidents, and other personally experienced, extreme stressors. PTSD stressors typically produce overwhelming fear. Burnout is of a different nature. Rather than feeling fearful and overwhelmed by discrete experiences as in PTSD, burnout produces a sense of emotional exhaustion that results from excessive giving of oneself, whether it be in support of others, or simply being unable to cope with the unremitting stress of job demands.

Traditional interventions for PTSD often involve some form of cognitive-behavioral psychotherapy (CBT) or prolonged exposure [15]. The essence of CBT is that cognitive distortions or irrational thoughts are the bases of emotional upsets. For example, a woman who is sexually assaulted by a person of a particular appearance or ethnic group may develop a fear reaction to all those who similar appearances. The dysfunctional thought here is that it is critical to be weary of anyone who bears a resemblance to individuals of that group. A similar dysfunctional thought might be that you cannot trust the environment at all and that one needs to seek isolation. Prolonged exposure involves directly confronting the trauma producing stimulus and doing so for multiple extended periods of time. In the case given above, the traumatized person would be encouraged to scrutinize pictures of individuals look like the person that assaulted her. She might then be asked to interact with them of a face-to-face basis. With repetition of such exposures, a reduction of anxiety eventually occurs because the traumatized individual comes to realize that there is no real threat.

From the above description of the treatment of PTSD it should be clear that burnout is different from PTSD. Burnout is not due to exposure to a defined stressor but is more generally a form of emotional depletion and as such, it requires different forms of intervention. The material that follows will describe what are referred to as “structural interventions” [16]. These interventions typically involve beneficial environmental changes that are not the individual psychotherapy types of interventions like CBT and prolonged exposure. Examples of structural interventions might be reducing one’s case load, altering the types of cases that are seen, engaging in distracting activities, obtaining more training or supervision, exercise, meditation, and others. The person experiencing burnout or compassion fatigue generally requires some form of alleviation of their stressors and not individual psychotherapy.

5. Structural interventions

Given that there is no specific set of empirically supported interventions for burnout, the following will be a sampling of variety of interventions that have been proposed in the literature.

Norcross self-care strategies [11]. These strategies might be employed by those who have experienced burnout from caring for ill family members or by healthcare providers who have reached their limit of giving. 1. Recognition. It is important to recognize that the type of activity in which one is engaged can be emotionally depleting “Affirming the universality of the hazards are in and of themselves therapeutic.”(p. 710). 2. Employ multiple strategies to alleviate stress, e.g., yoga, meditation, exercise, peer support, etc. 3. Self-awareness. This element involves self-reflection on ways one traditionally handles stress situations. 4. Employ multiple strategies for self-change rather that sticking to one. 5. Engage in changes such as changing one’s workplace or trying to make changes in one’s physical environment, while engaging to any of various diversions, e.g., team sports, exercise, fishing, knitting etc. 6. Emphasize the human element. For example, give more attention to friendships, peer groups, loving relationships, and participation in supervision groups. 7. Seeking therapy. Therapy need not be of the traditional CBT type, but rather a non-directive sharing of one’s emotional concerns. 8. Avoid self-blame and catastrophic thinking, i.e., magnifying one’s problems. 9. Seek diversity. For example, an EMT might engage in teaching activities in addition to their direct service. If providing care for an ill family member, one might consider bringing in others to help, or engaging the ailing person in games and other distracting activity. 10. Appreciate the rewards. Here Norcross is referring to allowing oneself to appreciate the importance of the work they are doing. Effort aimed at helping others is inherently worthwhile and worthy of praise.

Gilbert-Eliot ([17], p. 37) also lists a set of “proven strategies” for managing burnout and secondary trauma. These strategies include: Not bringing work home; change of or lighten of case load; schedule time off; engage in peer group support; actively engage supervisors to help in reducing the stress of work environments; and create change in the timing of one’s work schedule, e.g. perhaps putting the brunt of the demanding work in the morning where one might have more energy and lessening the demands later in the day.

Phipps and Byrne [18] provide counselling strategies to be used with those in volunteer counseling organizations, for emergency service personnel, medical personnel, and those involved in community-based services. These include supportive listening without pulling for details; using the burnout out or secondarily traumatized individual’s language for describing their trauma situations; normalizing, i.e., conveying to the trauma victim that their response was the expected one under the given situation; and teaching self-managed anxiety-reducing skills such as self-instructional training (SIT; [19]).

6. Social support

It has been previously mentioned [12] that social support is a crucial element in managing burnout, secondary trauma, and even PTSD reactions. People generally find the presence of others with whom they might share endured stresses can have a beneficial effect in terms of ameliorating the emotional consequences of this stress. Why social support is so beneficial is a complex subject and one writer [20] suggests that the positive impact of social support may be due to the cognitive assimilation of emotionally troubling experiences in the process of sharing them with others. The assimilation is facilitated by the feedback that might be received from others and is said to possibly reduce rumination and flashbacks.

There are, however, situations in which the seeking out of social support can have detrimental consequences. For example, the uniformed services may sometimes see the need for social support as an indication of weakness. Some uniformed service members take the position that strength means being able to handle stressors without needing the support of others. In fact, if an individual service member over relies on others, such activity might be a barrier to promotion. In one study [20] it was found that communication with police officer peers about troubling experiences that were experienced during their work had a stress buffering effect. However, too much communication was found to have a “reverse buffering effect” ([20], p. 419). In other words, moderate levels of communication about experienced stressors with peers was beneficial but higher levels were not. In contrast, communication with supervisors involving experienced stressors did not buffer the trauma-strain relationship. There have been many reported instances in which seeking help or communicating one’s distress was shown to have a negative impact on promotion and advancement. It is unclear why this might be so but it has been speculated that help seeking might run counter to stereotypical expectations of independence and strength among the uniformed services.

Despite the exceptions noted above, most research studies have shown that social support is a commonly accepted means of alleviating distress of the kind that leads to burnout and secondary traumatization. Human beings are often considered to be social animals and the need for social interaction and the benefit that comes from that form of interaction is substantial. The lack of support or the lack of availability of support is not only detrimental to one’s psychological functioning it is also associated with several physical ills [21].

7. Exercise

There is a substantial body of literature showing that exercise reduces various forms of distress including depression, anxiety, burnout, PTSD, secondary trauma, and many physical illnesses related to chronic stress [15, 22, 23]. While most of the research has been conducted on aerobic exercise, perhaps because it is easier to quantify than anaerobic exercise, there is general agreement in the literature that all forms of exercise are beneficial in ameliorating the deleterious effects of stress and burnout. Even though several hypotheses have been put forward as to why exercise is so beneficial, there is no universal agreement on the cause of these benefits. Among the hypothesized causes of the beneficial effects of exercise are the following:

7.1 Thermogenic hypothesis

This hypothesis proposes that the body temperature elevation that takes place during exercise results in a quieting impact on the nervous system. If this were valid then one would expect that those living in warmer climates would experience lower stress levels than those in colder ones. This has not been found and so the thermogenic hypothesis is not supported.

7.2 Endorphin and endocannabinoid hypotheses

The endorphin hypothesis is probably the most popular among the many speculations of the benefits of exercise. However, it has been found that there does not appear to be a strong correlation between circulating beta endorphin and mood states. Additionally, substances such as naloxone that block endorphins during exercise do not appear to have much of an impact on mood. And finally, endorphins have not been found to cross the blood-brain barrier, so it seems unlikely that endorphin production during exercise would impact the nervous system. A more recent alternative to endorphins is the endocannabinoids which are produced during exercise and which act on both peripheral and, unlike endorphins, the central nervous systems. Although a promising avenue for further research there is not an abundance of well controlled studies supporting the role of endocannabinoids in reducing stress reactions as seen in burnout and secondary trauma.

7.3 Monoamine hypothesis

Like the endorphin and endocannabinoid hypotheses, the monoamine hypothesis posits that certain substances or neurotransmitters released during exercise may have a quieting effect on affective states such as anxiety and depression. The specific neurotransmitters that have received a good share of the attention are dopamine, serotonin, and norepinephrine. The lack of substantial validation of the role of these neurotransmitters may be due to the difficulty in conducting such research on humans. One of the difficulties is that the assessment of emotional states such as anxiety and depression rely upon some form of self-report from a person engaged in exercise. The vagaries and unreliability of self-report measures are well known. An additional problem is that levels of neurotransmitter that are released during or shortly after exercise, would have to be obtained by way of invasive medical procedures such as spinal taps. Obtaining measures of neurotransmitters through urine samples does not provide information on levels within the central nervous system. The result of these difficulties in measurement leaves hypotheses involving neurotransmitters without a substantial body of empirical support.

7.4 Psychological hypotheses

Several psychological hypotheses have been put forward to explain the beneficial role of exercise in reducing anxiety, depression, and stress reactions that might be related to burnout and secondary trauma. In the interest of brevity, two will be mentioned here. The distraction hypothesis states that the mental focus needed to engage in exercise removes one from the kinds of rumination that lead to negative affective states. However, if this were the case, then any other distracting activity such as reading, watching TV, or doing housework should also reduce negative emotional states. There appears to be little in the research literature that presents a compelling argument for the distraction hypothesis.

The self-efficacy hypothesis is another mechanism that has been put forward to explain the beneficial role of exercise in reducing negative affective states. Self-efficacy is a term used to describe the self-perception of improvements in one’s capability to attain certain objectives. So, theoretically one might see increased competence in engaging in exercise as providing the beneficial mechanism of change. Unfortunately, available research shows that even when perceptions of increased competence in exercise are not attained, there are measured psychological benefits. In fact, single bouts of exercise where one cannot see improvement, has, in several studies, shown to have beneficial psychological effects.

In summary what the available research shows is that one of the ways of reducing the debilitating effects of burnout is through exercise. The form of exercise can be aerobic, not anerobic, or even stretching activities. Why this is so is the source of considerable debate. For the person who is shouldering the negative impacts of burnout, it is likely the reasons that exercise is beneficial are less important than the fact that there is ready access to an activity that has been repeatedly shown to be both psychologically and physically beneficial.

8. Mindfulness meditation and yoga

Meditation and yoga are being presented together because they have both been shown to alleviate the distress that is commonly seen in burnout, secondary trauma, and primary psychological traumas [15]. While mediation usually involves focal attention while sitting quietly and yoga commonly entails the enactment of balanced poses and stretches (asanas), they both call upon the need to take one’s attention away from ongoing concerns and worries and to direct it narrowly on specific stimuli.

8.1 Mindfulness meditation

While meditation is a practice of focal concentration, it might be argued that mindfulness meditation is a specific form of meditation involving a focus on what is taking place now, in this moment, as opposed to a focus on concepts such as gratitude, love, world peace, etc. A focus on what is taking place now might involve a focus on one’s breathing, how each part of the body feels as one sits on a meditation cushion (a zafu), the coolness of the air on one’s skin, or one’s breathing as the air enters and exits the lungs. One popular writer describes mindfulness meditation as “Mindfulness means paying attention in a particular way: on purpose, in the present moment, and non-judgmentally ([24], p. 4). The objective in mindfulness meditation is to attempt to stop the normal wanderings of the mind and to focus it. There might be a focus on the rising and falling of one’s diaphragm as they breathe in and out. They might note the air passing through their nostrils and the feelings of coolness. They might note how their buttocks feel as they sit on the zafu. When the mind wanders, at it inevitably will, the attention is brought back to the initial focus repeatedly.

A typical mindfulness session lasts approximately twenty minutes, and it is generally recommended that practice takes place daily. When one reads about meditation practice, it seems easy, but the research suggests that this is not the case. There are two primary difficulties. The first is that focusing one’s attention and not being distracted by intruding thoughts, worries, and concerns is difficult. Many report that it takes years to become competent at the practice of not letting wandering thoughts intrude. The second difficulty is that meditation must be practiced somewhat like exercise is practiced. One does not engage in exercise once or twice and expect lasting benefits. Meditation, like exercise, to be effective in warding off burnout, must become a lifelong practice. There are many meditation practices that can be found in the literature, online, on phone apps, in workshops, etc. What is important is not the finding of the “right” meditation, but rather finding the one that that will be done regularly and with sincerity of purpose [24]. No one can say with certainty why mindfulness meditation reduces the stresses commonly seen in burnout or why it brings harmony to most of those who practice it regularly and who may not be enduring excessive stresses. Nevertheless, there is abundant research and metanalytic studies that support the value of mindfulness meditation in reducing stress and bringing about a more gratifying perspective on life.

8.2 Yoga

There are similarities between mindfulness meditation and yoga. They both involve a focusing of attention, the exclusion of intruding and troubling thoughts, a reduction in stress, and the development of a more positive perspective. Yoga and meditation have been practiced for thousands of years and it has been argued that yoga is a form of meditation that takes place while engaging in various postures and stances or asanas. In Sanskrit yoga means “union” or “connection,” and what is being united is the body and mind [25]. People who experience burnout or other forms of traumatization try to separate from themselves or push away from the unwanted memories and images that have caused them distress. The practice of yoga is one of uniting, of pulling back together, of reintegrating. Regardless of whether the data in support of yoga for dealing with various forms of psychological trauma is electrophysiological, self-report, or behavioral, the available empirical research supports its value in dealing with trauma situations and burnout. Most Veterans Health Administration Centers for the treatment of various forms of trauma include yoga among their offerings [15].

There are approximately 30 different types of yoga that are practiced in the United States [26], but this is likely to be an underestimate. The types differ in terms of whether they are for beginners, intermediate, or advanced practitioners. They also differ in terms of the precision with which they are practiced, the temperature of the room, the overall vigor or activity level that they entail, the degree to which formal meditation is part of the practice, whether the meditation emphasizes focus (dharma) or absorption (dhyana) or oneness (samadhi), the degree to which certain breathing techniques are utilized (pranayama), and others. A partial listing of the names of the various types of yoga are Anusara, Ashtanga, Bikram, Hatha (one of the oldest and most popular forms), Iyengar, Jivamukti, Kripalu, etc.

One of the more recent modifications of yoga is to have the yoga instructor be less directive and more accepting of variations in the practice of the different postures or asanas. The reason for this is that many of those who have been traumatized or have experienced burnout often feel out of control of their environments. By allowing the practitioner more say in how the yoga session is to be conducted, the instructor will likely lessen the perceived stress to the yoga session and attain more beneficial outcomes of the yoga practice. In all, however, yoga and meditation have both proven themselves to be healthy and effective way of dealing with burnout and other forms of trauma.

9. Animals and outdoor environments

9.1 Animals

The presence of animals has been associated with stress reductions of the type that is often seen in burnout, primary, and secondary trauma including PTSD. Spending time with animals can reduce anxiety, depression, and isolation while increasing levels of exercise, trust, and playfulness. Human have kept animals for companionship and stress reduction throughout history [26]. Archaeologists have uncovered the remains of a puppy in the arms of a human as early as 10,000 BCE. Cats and other pets have been found in the presence of humans many thousands of years ago. There is an intimate bond between humans and various animals and these human-animal bonds have been associated with lowering of blood pressure, less cardiac disease, strokes, etc. in addition to the previously noted psychological benefits. Within the last decade “service” animals have become a commonly accepted phenomenon and they are commonly accepted in public establishments that previously excluded them. Not everyone is a fan of animals, but surveys show that most people are positively disposed to them. Animals are a valuable resource to those who experience the depletion, irritability, cynicism, unhappiness, and tendency toward isolationism that is often seen in burnout.

There is abundant and compelling research on the use of service dogs with military veterans who have been traumatized by their combat experiences and have become isolated and withdrawn. In one study [27] veterans were paired with service dogs who were trained to identify when the veteran was having nightmares, anxiety reactions, depression, and withdrawal from the environment. The service dogs also learned to form a barrier between the veteran and others when closeness began to create anxiety. Another group of veterans was not paired with service dogs but had applied to have them. Among the findings were that those with service dogs had lower scores on standardized measures of depression, anxiety, and PTSD. They had more social interactions, fewer absences from work, fewer avoidance and withdrawal responses, and fewer medical visits and need for medical interventions.

While there have been fewer studies of the impact of animals on secondary trauma and burnout our relationship with animals has many health benefits. The research shows that a surprising array of animals can have a positive impact in addition to dogs. The list includes cats, horses, fish, reptiles, rodents, pigs, and many more. The individual who experiences burnout is a person feeling the painful effects of emotional depletion. Animals, in their relationship with humans, refill the emotional void. They are trusting, loving, and accepting. In healthcare facilities, it has been found ([28], p. 7) “An animal’s unconditional, unbiased, and abiding love is very rewarding to witness in actions. It elicits smiles, encourages movement, and stimulates conversation, play and interactions. Love from an animal encourages reminiscing, provides nurturing, and produces enjoyment. It encourages therapeutic touch, increases self-esteem and, most importantly, provides a home-like atmosphere in any setting.” Overall, the presence of animals is one of the important resources that should be considered when dealing with the ravages of burnout.

9.2 Outdoor environments

Immersion in nature can also be an effective way of reducing the negative impact of burnout, compassion fatigue, and secondary trauma. The naturalist Edward O. Wilson [28] coined the term “biophilia” to describe the seemingly innate desire to immerse oneself in natural settings. The psychological study of nature’s impact is sometimes referred to as ecopsychology. The Japanese appear to appreciate the health promoting effects more fully than do those from the U.S. They endorse regular excursions into natural environments as a way of alleviating the distress particularly among those involved in professional activities. The Japanese use the term shirin yoku or “forest bathing” to describe this immersion in nature [29].

It is difficult to design empirically defensible individual studies to assess the benefits of natural environment immersion. Such studies would be expected to have random assignment, double-blind procedures, objective methodologies, and the use of psychometrically validated assessment instruments. Rather than attempt to construct such studies one can combine reasonably well controlled studies with some less well controlled ones and place the additive results in a meta-analysis that examines “effect sizes.” A common definition of an effect size in statistics is a standard deviation of difference. So, if one study’s mean is one standard deviation different from that of another study, the effect size would be 1.0, which is considered a large effect size. Medium effect sizes of about .5 are accepted as meaningful, while small effect sizes of .3 do not instill great confidence of a difference between groups.

Bowen and Neill [30] conducted a meta-analysis of 197 studies of immersion in nature and were able to report on 2900 effect sizes across different measures relevant to the calming effect of natural environments. The mean effect size in this study was found to be .5, a medium and meaningful effect size. By way of comparison, these authors report that individual psychotherapy has an effect size of .67 which is also a medium effect size. The implication here is that natural environments have a positive impact that is comparable to that seen in individual therapy. The authors examined the impact of no immersion in nature and found a small effect size of .08. The various nature programs in this study included simple walks in nature to natural adventures in which participants engaged in environmental challenges such as crossing active streams and climbing up steep inclines. The positive impact of natural environments in seen for all ages studies and seems to have its greatest impact on older adults. Following a careful evaluation of the obtained data, one study [31] found that a minimum of two hours per week in nature is required to have a significantly positive impact of lessening anxiety and depression, and on the emotional exhaustion that follows from secondary trauma and burnout. Overall findings of these various studies strongly suggest that those experiencing burnout can obtain some degree of relief by regularly spending time in nature.

10. Conclusion

The origin of the terms, “burnout” and “burnout syndrome” has been attributed to the psychoanalyst Herbert J. Freudenberger in the 1970s. Since then, these terms have become important concepts in the psychological literature. Freudenberger was immersed in “free clinics” in the San Francisco area and his writings suggested that many clinicians, and perhaps he himself, began to show signs of emotional exhaustion, depression, anxiety, and weakened immune systems, after extended periods of providing services to needy clients. The free clinics, as the name implies, provided services at no expense and the providers volunteered their services, also for free. Burnout has since been reported to occur among individuals who care for family members, first responders, health service providers, and anyone else who gives of their energies to excess.

Interventions for burnout do not fall within the umbrella of cognitive-behavioral psychotherapy and/or exposure therapy. These approaches are said to be the treatments of choice for conditions such as specific anxieties and phobias, depression, and PTSD. Burnout interventions, in contrast, involve structural changes within the work setting such as reducing the number of contact hours or altering the content of the services that are provided. Other interventions are aimed at stress reduction, and these are alternative therapy approaches such as increased social contact, yoga, meditation, exercise, spending time with animals, or immersing oneself in natural environments. There is a need for additional quality research studies on the most effective interventions for burnout and burnout syndrome, and this research is currently being amassed, but is not as well developed and established as that body of research which is relevant to traditional disorders such as anxiety and depression.

11. Summary

There is a general lack of empirical data that would support the favoring of one type of intervention over others for the treatment of burnout. What does seem clear is that the traditional CBT interventions that are employed for disorders like PTSD are unlikely to be effective in burnout (e.g., [15]). What we are left with individual empirical studies, some of which are reported in this book, along with is anecdotal reports that are provide support for a variety of interventions. These interventions include changes in the work environment and personal self-care strategies. Table 1 summarizes these interventions and includes relevant references.

Structural interventions such as reducing workload and restructuring workday [11, 17, 18]; Social support [12, 20, 21]; Various forms of exercise [15, 22, 23]; Mindfulness meditation [15, 24]; Yoga [15, 24, 25, 26]; Interaction with animals [27, 28]; Spending time in outdoor environments [29, 30]; Self-care strategies [11, 18, 19]

Table 1.

Proposed interventions having potential for lessening burnout.