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Burnout in psychiatrist

Article in World psychiatry: official journal of the World Psychiatric Association (WPA) · November 2007
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IMP. 186-189 24-09-2007 16:12 Pagina 186

MENTAL HEALTH POLICY PAPER

Burnout in psychiatrists
SHAILESH KUMAR
Department of Psychiatry, Waikato Clinical School, Private Bag 3200, Hamilton, New Zealand

Psychiatrists as a group are vulnerable to experiencing burnout, more so than other physicians and surgeons. In this paper, various defi-
nitions of burnout are reviewed and the tools available for quantifying burnout are compared. The factors that make psychiatry a stress-
ful profession are also examined. These include factors such as patient violence and suicide, limited resources, crowded inpatient wards,
changing culture in mental health services, high work demands, poorly defined roles of consultants, responsibility without authority, in-
ability to effect systemic change, conflict between responsibility toward employers vs. toward the patient, and isolation. In order to in-
vestigate how exposure to such stressors results in burnout, two theoretical models are examined. Recommendations are also made, on
the basis of anecdotal reports, for addressing burnout in psychiatrists.

Key words: Burnout, psychiatrists, stress management, workforce

(World Psychiatry 2007;6:186-189)

Psychiatrists have a stressful life. They use themselves as ciency and inadequacy). This definition of burnout has been
“tools” in their profession and experience a range of power- the most widely used in literature.
ful emotions in their clinical work. The doctor-patient rela- While burnout may have a negative impact on workforce,
tionship in itself evokes emotions such as the need to rescue patient care and the individual’s health, it may also play a
the patient, a sense of failure and frustration when the pa- protective role. The symptoms of burnout have been hypoth-
tient’s illness progresses or does not respond to treatment, esized to appear in order to protect human psyche against
feelings of powerlessness against illness and its associated further damage in the face of “having no way out”. Freuden-
losses, grief, fear of becoming ill oneself, or a desire to sepa- berger (8) describes depersonalization as a means of protec-
rate from and avoid patients to escape these feelings (1). tion against further emotional draining or a homeostatic
Given the personal nature of the relationship psychiatrists mechanism in an emotionally exhausted worker. Along sim-
have to develop with their patients, these emotions are like- ilar lines, one may argue that emotional exhaustion acts as a
ly to be intensified in their context. Psychiatrists are also ex- “brake” for individuals who may not know how or when to
posed to external stressors, due to the rapidly changing slow down. Negative changes in attitude (reduced work
ways of service delivery, the widening gap between the way goals, loss of idealism, heightened self interest, increasing
they are trained and the way they practice, and the increas- emotional detachment from clients) have been described by
ingly complex administrative and legal frameworks. Benbow (3) as a form of coping.
While stressors may originate from a variety of sources Standardized and valid instruments have been developed
and may vary with settings and disciplines, the outcome of for the measure of burnout. Two are currently popular: the
chronic exposure to emotional and interpersonal stressors Maslach Burnout Inventory (MBI, 9) and the Burnout Mea-
on the job is invariably burnout (2,3). This paper examines sure (BM, 10). The MBI gives scores on the three subscales
the concept and causes of burnout and the relevant inter- or dimensions of depersonalization, emotional exhaustion
ventions as they apply to psychiatrists. and lack of personal accomplishment, by determining how
people respond to each of 22 statements on a scale of 0-6.
The higher the respondents score on depersonalization and
BURNOUT: DEFINITIONS AND MEASURES emotional exhaustion, the higher their levels of burnout,
while the lack of personal accomplishment scale measures
The concept of burnout was first introduced by Freuden- in the opposite direction. The inventory has been found to
berger (4). Since then, various definitions have emerged. be reliable, valid and easy to administer. The BM contains
Kuremyr et al (5) defined burnout as “an experience of 21 items (rated on a 7-point frequency scale) grouped into
physical, emotional and mental exhaustion caused by long- three subscales (assessing physical exhaustion, mental ex-
term involvement in situations that are emotionally de- haustion, and emotional exhaustion). Unlike the MBI, the
manding”. Lee and Ashforth (6), referring to Maslach and items have no explicit association with work and are pre-
Jackson’s (7) work, defined burnout as a syndrome of emo- sented in random order. The subscales have shown good
tional exhaustion (tiredness, somatic symptoms, decreased (.80 to .90 range) internal consistency (11), and the total
emotional resources, and a feeling that one has nothing left scale has shown a 1-month test-retest reliability of .89 (12).
to give to others), depersonalization (developing negative, As with the MBI, factor analytical studies suggest that the
cynical attitudes and impersonal feelings towards their BM is a unidimensional measure (11). Others have shown a
clients, treating them as objects) and lack of feelings of per- high correlation between the total BM scores and the scores
sonal accomplishment (feelings of incompetence, ineffi- on the MBI emotional exhaustion scale (12).

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IMP. 186-189 24-09-2007 16:12 Pagina 187

WHAT CAUSES BURNOUT IN PSYCHIATRISTS burnout does not dilute their pleasure derived from work.
Alternatively, while psychiatrists may be good at picking up
In order to understand psychiatrists’ susceptibility to changes in their mood state, they may believe that practising
burnout, one needs to examine the factors that make psy- psychiatry in an exhausted state is part of their job (27). This
chiatry a stressful profession. Deahl and Turner (13) identi- peculiarity of psychiatrists as a group renders any model
fied violence and the fear of violence, limited resources, that relies on job satisfaction as a protective factor weak.
crowded inpatient wards and an increasing culture of blame A study of psychiatrists and psychiatric residents investi-
creeping into the mental health services as the main sources gated the relationship between demographic factors, work
of stress for psychiatrists. High work demands without ade- and leisure activities. Personality was assessed by the Mu-
quate resources, poorly defined roles of consultants, re- nich Personality Test (MPT) and burnout with the Tedium
sponsibility without authority, inability to effect systemic Measure (TM) (28). Psychiatric residents reported signifi-
change, conflict between responsibility toward employers cantly higher scores on TM and neuroticism, but lower
vs. toward the patient, isolation of consultants in communi- scores on frustration tolerance on MPT. The study found that
ty mental health teams and lack of feedback were identified neuroticism alone explained a substantial proportion of the
as sources of stress by Thompson (14). A qualitative study of total TM variance. Work-related variables turned out to be of
mental health professionals in a well-resourced community a small importance only, whereas no influence could be
mental health team including psychiatrists (15) identified demonstrated for different leisure activities. Another study
administrative demands, lack of resources, work overload, (29) reported that, as a group, psychiatrists differed signifi-
responsibility for patients and relapsing patients as the top cantly on various personality measures from physicians in
five sources of stress. Overt bureaucracy, high workload and other disciplines. They scored higher than physicians and
the lack of free time were reported as the factors which may surgeons on items of neuroticism, openness and agreeable-
either be responsible for premature retirement by specialist ness, but lower on conscientiousness. Even though psychia-
psychiatrists or be reasons why juniors would not pursue trists reported less clinical work demands, they reported
psychiatry as a career option (16,17). A large survey of psy- higher work-related emotional exhaustion and severe de-
chiatrists identified out of hours or long hours of duty, deal- pression than physicians and surgeons. These findings imply
ing with difficult and hostile relatives of patients, arranging that the very personality characteristics that attract people
admissions, paper work, balancing personal and profes- towards pursuing psychiatry as a career may also render
sional lives and managing suicidal or homicidal patients as them sensitive to stressors.
particularly stressful experiences (18). Another recent paper (30) examined the interaction be-
It is important to note that not every psychiatrist who is tween four sets of factors proposed to be responsible for
exposed to such stressors for extended periods develops burnout: predisposing, precipitating, perpetuating and pro-
burnout. Holloway et al (19) describe an interactive model tective. Many of the factors that were recognized as exter-
that examines the relationship of the external stressors out- nal, internal and mediating in Holloway et al’s model (19)
lined above with mediating factors and stress outcome. To were encompassed in the above four “P” model, which also
cite their example, “the poorly functioning doctor who lacks identified some systemic factors responsible for burnout,
appropriate coping mechanisms and ends up working in an raising the possibility that reducing stress through these sys-
impoverished service may well experience more occupa- temic issues could reduce burnout in psychiatrists.
tional stresses than his or her more successful peer working The above study (30) pointed out that psychiatrists may be
within a well resourced and professionally rewarding ser- predisposed to burnout due to their personality traits, which
vice. Overwhelming personal or professional life events (e.g., make them prone to internalize their stressful experiences.
a patient homicide) may lead to decompensation of even Their training experience may also play a significant role in
most resilient and best supplied professional”. Positive mo- the causation of stress and burnout: psychiatric trainees are
tivating factors or sources of job satisfaction, such as appre- more closely involved with people’s personal difficulties than
ciation for job done well, responsibility for others, personal trainees in other disciplines, and often labour feelings of self-
advancement and salary enhancement, may play an impor- doubt, fear, and fatigue (31). Psychiatrists are trained in long-
tant role in the final outcome of stress exposure. term verbal interventions, but they are invariably employed
An inverse relationship between stress and job satisfac- to deliver short-term and mainly biological treatment modal-
tion has been reported in lawyers (20), rehabilitation work- ities (32). Furthermore, it appears that workload on psychia-
ers (21) and public service employees (22). Surprisingly, trists is set to increase globally due to increasing population,
such relationship does not appear to exist for psychiatrists: a progressive move to community-based treatment, increas-
despite experiencing depression and burnout, they can con- ing involvement in administrative roles, increasing standards
tinue to enjoy their work and consistently score high in job of practice, greater expectations by doctors to have time for
satisfaction surveys – a finding reported from the UK (23), study and relaxation, as well as diminishing numbers of those
Australia (24) and the USA (25,26). One could speculate choosing to go into psychiatry (33-36). In other words, psy-
that psychiatrists as a group are so committed and passion- chiatrists as a group are predisposed to experience stress due
ate towards their work that the exhaustion associated with to internal and external factors.

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IMP. 186-189 24-09-2007 16:12 Pagina 188

Against the background of these predisposing factors, three intervention studies that had used samples of “mental
psychiatrists are invariably exposed to triggers that precipi- health professionals” including psychiatrists. However, for
tate burnout. Violence perpetrated by patients is widely reasons identified above, it might not be appropriate to
prevalent in mental health services (37-41) and is widely lump psychiatrists with other mental health professionals
recognized as stressful for all psychiatrists, irrespective of when it comes to either stressors or responses to stressors
their level of experience (42). Most psychiatrists experience including burnout. In the absence of any well-designed in-
patient suicide and are invariably adversely affected by it terventional studies, one may have to look at anecdotal re-
(43,44). On-call duties and dealing with difficult and hostile ports. Holloway et al (19) listed interventions focusing on
relatives have also been described as distressing events in the individual (such as social skills training, stress manage-
psychiatrists’ profession (18). ment interventions, social support and time management)
The final appearance of burnout may depend on how one and on the organization (defining role and job characteris-
perceives and responds to stressful situations. Factors that tics, improving interpersonal relationships, encouraging de-
affect such appraisal styles (so-called perpetuating factors) centralization in the organizational structure and improving
are instrumental in determining whether the stress originat- the physical environment of work place). The authors em-
ed at work may or not translate into burnout. Gender plays phasized the importance of formal support through regular
a significant role in the perception and origin of stress and feedback and appraisal of psychiatrists’ performance, which
consequently in the way one responds to stress: women re- need to occur even in the absence of any identified problem.
spond to stresses through career dilution and diminution
(working part time) and/or by using strategies to limit de-
mands on intimacy (45). Personality traits may also play a CONCLUSIONS
significant role in predisposing psychiatrists to experience
burnout and in perpetuating the phenomenon once it sets in Burnout is a serious consequence of chronic exposure to
(46). Certain systemic factors have been identified that con- work-related stressors. As a group, psychiatrists are at a high
tribute to psychiatrists’ stress and therefore possibly risk of experiencing burnout, due to external factors such as
burnout: they include changes in health service delivery work environment, internal factors such as personality and
model, clinician management conflicts, and time manage- appraisal styles, and mediating factors such as support and
ment and resource issues (47,48). resilience. The onset of burnout can be seen as a conse-
quence of the interaction between predisposing, precipitat-
ing, perpetuating and protective factors. While factors that
PROTECTIVE FACTORS AND are protective against burnout and therefore may have a pre-
INTERVENTIONS FOR BURNOUT ventive role have been identified, there is a lack of studies
evaluating the efficacy of interventions once burnout has set
There are factors protecting psychiatrists against burnout. in. Anecdotal evidence suggests that support through peers,
Some evidence suggests that lifestyle factors and paying at- organization or family/friends may be effective against es-
tention to one’s non-professional life may have a protective tablished burnout.
effect (49). Academic work has been reported (50) to be neg-
atively correlated with depersonalization, emotional exhaus-
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