Burnout and Psychotherapy
Christian Jonathan Haverkampf, M.D.
Burnout is largely determined by how connected one is with oneself and others. The quantity of messages from oneself and the world is not what causes burnout, but how one selects and processes the messages, which is also related to the ability to draw healthy boundaries. Openness and transparency can prevent burnout on an organisational level. On an individual level, the communication with oneself is important, the identification of own needs, values and aspirations. Treatment of burnout needs to focus on the self-communication, the discovery of more meaning in one’s daily life, and especially so one’s true values, interests and aspirations, and on the communication used in interaction with others. In therapy, awareness for and experimentation with communication patterns and styles in self-communication and communication with others is very helpful in the treatment of burnout and the symptoms associated with it.
Keywords: burnout, psychotherapy, treatment
Make an Appointment with Dr Jonathan Haverkampf
Table of Contents
Values, Interests and Aspirations. 5
The Professional Environment. 6
3. Communication with Others. 8
Burnout is a state of persistent exhaustion, which is work related and characterized by emotional exhaustion, cynicism, or depersonalization and reduced competence (Maslach, Schaufeli, & Leiter, 2001). The emotional exhaustion often shows in emptiness the sense of feeling depleted emotionally and numbness. These symptoms result from prolonged periods of high workload or persistent or recurrent stress without sufficient recovery. Chronic stress leads to changes in the adaptive state (allostasis) of the body, which may lead to wear and tear and to an allostatic load in the long run (McEwen, 2000). The basic mechanism of burnout is a disconnect from oneself and others. (Haverkampf, 2013, 2017)
The goal of therapy is to reverse the communication disconnects with oneself and others. At the same time, burnout can have organizational and societal causes which contribute to it. Transparency, openness and promoting helpful connections prevents burnout, while a lack of those can make burnout more likely. Everything that promotes the exchange of meaningful messages reduces the risk for individual disconnect and burnout, while everything that interferes with it increases the risk.
Burnout is largely a product of the society we live in and our interactions with it. The more we are in communication with others, the more messages we receive and send, the higher is the chance for collaborative success, but the greater is also the risk of burnout, especially if we do not know what goal we are chasing or why we are doing our daily routine. The problem is most often not that the world is faster or more interconnected, but that many people do not know the reasons they are going after in their day-to-day lives. A group, company or society that promotes disconnect is at a greater risk of burnout on an individual and also on an organizational level. It is then also at a risk of stagnation, rigidity, lack of openness, flexibility and innovation which are both contributing factors or burnout and a result of it.
Burnout can be devastating for an individual. It can take away a sense of the future, jobs and relationships, but worst of all it makes one disconnected from oneself, which distances one even further from autoregulatory mechanisms to take care of oneself, draw health boundary and make decisions in life. Disconnected from one’s emotions and critical thought processes, one becomes numb and removed from one’s needs, values and aspirations. People often describe it as feeling like a robot or a hamster on a wheel.
The solution for burnout is better communication and helpful connections, so that a patient can find more meaning in his or her daily life, which also helps in identifying true values, interests and aspirations. The road to get there is through better communication with oneself and with others.
From a psychophysiological point of view, the symptoms of burnout reflect disturbances of neural and hormonal stress-regulatory systems. The central neuroendocrine system involved in long term adaptation to stress is the hypothalamus pituitary adrenal (HPA) axis, with cortisol as its major regulatory hormone (Cook, 2002; Sapolsky, Romero, & Munck, 2000). The HPA axis is interconnected with other regulatory systems that are involved in regulating the energy balance, mood states, sleep, and cognition. A disturbed HPA axis could therefore have an impact on these systems (Raison & Miller, 2003), causing the array of symptoms as observed in individuals with burnout. Disturbances in the HPA system are also evident in other stress-related pathologies such as chronic fatigue syndrome (CFS), depression, and posttraumatic stress disorder (Ehlert, Gaab, & Heinrichs, 2001; Parker, Wessely, & Cleare, 2001). Higher cortisol levels are a characteristic of major depression (Holsboer, 2001; M. M. Pruessner, Hellhammer, Pruessner, & Lupien, 2003). Posttraumatic stress disorder and CFS, however, if anything, rather show a hypo function of the HPA axis (Demitrack, 1997; Heim, Ehlert, & Hellhammer, 2000; Parker et al., 2001; Roberts, Wessely, Chalder, Papadopoulos, & Cleare, 2004). Because the clinical symptoms of these illnesses are overlapping with burnout, a deviation of the HPA axis may be associated with burnout as well. Cortisol secretion shows a circadian rhythm, it peaks in the morning and then gradually declines during the day. Another aspect of cortisol secretion is the so-called cortisol awakening response (CAR). This acute rise, superposed on the normal cycle, reaches its peak about 30 min after awakening. The CAR is found to be altered in situations of stress and high job strain, showing higher awakening levels and a steeper increase (Schulz, Kirschbaum, Pruessner, & Hellhammer, 1998; Steptoe, Cropley, Griffith, & Kirschbaum, 2000; Wust, Federenko, Hellhammer, & Kirschbaum, 2000). A pilot study showed a reduction in morning cortisol levels of persons suffering from burnout complaints, possibly pointing to a state of exhaustion. These morning cortisol levels were increased after 14 treatment sessions. The increase, however, showed no quantitative relation to the improvement in symptoms of burnout.
The Social Setting
Burnout was probably rare in stone age societies, and it takes highly artificial conditions to induce burnout in animals. While it is possible to induce burnout symptoms in lab rats when they are exposed to persistent stimuli causing high levels of negative stress and arousal, this is unlikely to occur outside the lab. However, under these conditions the animals show symptoms that are similar to those of people suffering from burnout. They have low tolerance for even minor stimuli, such as noise, and seem to experience helplessness and high levels of psychological distress. Their life expectancy is reduced, they no longer eat regularly, often lose weight, show signs of exhaustion and after a while suffer from bodily conditions that ultimately lead to an early death. They seem to have learned that they are helpless and that their avoidance behaviour is ineffective. Like people they seem trapped in a hopeless situation, but, unlike humans, they really are.
Values, Interests and Aspirations
Burnout is often approached from the wrong angle. It does not require behavioural changes at first, but the sense of purpose and why one is engaged in an activity. This requires a reflection of past activities and situation and connecting with oneself to an extent that one can say whether this fulfilled a need, a value or an aspiration. This connection can be promoted in a therapy which focuses on awareness for and experimentation with communication with oneself and others.
Many people go through life without thinking about their values, interests and aspirations. Some may be living them naturally, but in a more complex world which requires conscious decisions it becomes necessary to become consciously aware of them. Equally, many people do things on a daily basis that do not bring much happiness and enjoyment, which increases the risk for a number of psychiatric conditions, among them burnout. Unfortunately, many people think they cannot afford to think about questions of needs, values and aspirations because it might change their life dramatically. But this is not the objective of knowing what you truly value and are interested in. The point is to make better decisions in the future.
The Professional Environment
Being a care provider or teacher in a less than ideal environment often leads to burnout if one has a need to ‘give it all’ and ‘care for others as if this were the last day’. Although burnout can occur over time in a variety of situations, it is mainly triggered by events in the workplace or in a relationship. The external cause is usually a prolonged external stressor, such as a mobbing situation or an unhappiness with the current job or relationship. The internal causes are often preconditioning personality aspects, such as the inability to say ‘No’ or to keep an appropriate distance to other people’s problems. It almost always requires both, the external and the internal factors, to lead to a full-blown burnout. If I feel secure and confident with myself, I might just leave the job where I get mobbed and so avoid burnout. On the other hand, working in a loving and caring environment will probably not lead to burnout, even If I cannot say ‘No’.
Burnout often requires professional help because it comes with the sense of hopelessness and helplessness, which tends to make ‘self-help’ difficult. Communication is the most powerful instrument for change when it comes to burnout. Patients with burnout have lost touch with themselves and others. Humans need communication with meaningful messages, that they can use to regulate themselves and change the world around them. In the case of burnout, one often observes a freezing of the personality to become rigid and brittle in the face of change, as well as the fear of potential fragmentation and disintegration from it. The self is imprisoned and communication dies down because any change or influence seems extremely stressful.
There are a few central steps that need to be taken, whether one tries to deal with the issue oneself or works with a professional, all aim at a more flexible and open communication that allow the individual the freedom to look at what it is truly important to him or her:
First, it is important to realize that one is experiencing an actual or potential burnout situation. Without this acknowledgment, it is difficult to face the resistance not to touch one’s routines, thought and behavioural patterns. It also helps with the aversion to change. There may be fears that one may have to make undesirable changes but doing almost anything that creates extra breathing space to think and reflect and avails room for change, effectively counters the sense of hopelessness and helplessness that is central to burnout.
Secondly, assessing one’s values, needs, wishes, dreams and aspirations, and having a vision of what life might look like in the future paves the road to successful change. It also means assessing and analysing the feelings that are associated with thinking about the future. Depressed thoughts and negative emotions are relatively common in burnout and thinking about the future can seem meaningless or even painful. Assessing one’s situation in the safe environment of a therapy session does not have to mean immediate change, but it helps to fight the hopelessness and helplessness that are associated with burnout.
3. Communication with Others
Thirdly, since burnout manifests in the interactions and relationships we have with others, it requires looking at one’s own communication patterns and how best to respond to someone else’s unhealthy communication style. How we interact with other people is shaped by our past life experiences, and if they have not been so good, they can make us fearful even in the present. If your father was given to unpredictable emotional outbursts, you may be fearful in situations with your boss, a (male) authority figures. Since the father’s behaviour was not predictable, you feel helpless. Feeling helpless and hopeless, you are unlikely to reflect on how to defend yourself effectively and on understanding the dynamic between you and your boss, which could help both of you. The world has become an unpredictable place, you are on constant alert at the workplace and this will ultimately lead to burnout when the exhaustion takes its toll. Maintaining the space to take a step back and reflect on the situation can prevent this.
Building new communication patterns requires insight in the present ones, which can be developed through reflection in the therapy sessions. Good communication patterns and a sense of knowing where one stands and where one would like to go next are affective antidotes to burnout. Change should occur in steps that can be planned and reflected on. The future does not have to be mapped out in any detail, as this deprives us of the possibilities that are not yet known to us. But one should sort out one’s fundamental values, one’s needs, and the things one would be unwilling to compromise on, as well as have an idea in which general direction the journey should go next. A lack of sense of direction makes one more susceptible to stress, pressure and burnout. Have the courage to visualize the future.
4. Perceiving Relevance
Fourth, it is important to determine the relationships and things which are helpful and which are not. This may not always be easy to tackle because of fears that this could lead to people turning away or even loneliness. But there is no reason to threat it, because it really means taking control of one’s social life rather than losing it. Meaningful change is good, hasty decisions almost never.
5. Making Decisions
Fifth, as you become clearer about yourself and your interactions with the environment and your communication patterns improve, you will gain trust in your ability to shape your environment. You will also notice a greater attraction on other people. The negative voice in the back of your head telling you that you don’t know what you are doing dies away. As you gain greater trust in yourself, you have more faith in your internal compass, and this effectively prevents anxieties, burnout and a number of other conditions. This will also bring greater clarity about the values and interests that are important to you. This makes decisions easier and helps you orient yourself towards the future.
Self-confidence is best built by not thinking how to get it, but doing the things you would do if you had it. This requires thinking about the things you like to do, as well as your values and aspirations. What challenges you in a positive way? What gives you pleasure? Achievements only improve your self-confidence if they resonate with your values, needs and aspirations. Many people are afraid to look deep down into themselves to find answers, not necessarily because they assume there is something unpleasant, but because they fear they might encounter a void. This is why it is helpful thinking about one’s values, needs and aspirations, because they are there no matter what.
Sixth, taking new perspectives on the world and developing greater openness to the good things in life develops automatically if you do not give up and get the help you need. Take a new look at the world and be open to what it tells you. Burnout is a closure of the mind, and the best antidote to it is to open one’s eyes and engage with oneself and the world.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Broadbent, D. E., Cooper, P. F., FitzGerald, P., & Parkes, K. R. (1982). The Cognitive Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical Psychology, 21, 1–16.
Cook, C. J. (2002). Glucocorticoid feedback increases the sensitivity of the limbic system to stress. Physiology and Behavior, 75, 455– 464.
Demitrack, M.-A. (1997). Neuroendocrine correlates of chronic fatigue syndrome: A brief review. Journal of Psychiatric Research, 31, 69 – 82.
De Vente, W., Olff, M., Van Amsterdam, J. G. C., Kamphuis, J. H., & Emmelkamp, P. M. G. (2003). Physiological differences between burnout patients and healthy controls: Blood pressure, heart rate, and cortisol responses. Occupational and Environmental Medicine, 60, 54 – 61.
Dressendorfer, R. A., Kirschbaum, C., Rohde, W., Stahl, F., & Strasburger, C. J. (1992). Synthesis of a cortisol-biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. Journal of Steroid Biochemistry and Molecular Biology, 43, 683– 692.
Ehlert, U., Gaab, J., & Heinrichs, M. (2001). Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: The role of the hypothalamuspituitary-adrenal axis. Biological Psychology, 57, 141–152.
Grossi, G., Perski, A., Ekstedt, M., & Johansson, T. (2004). The morning salivary cortisol response in burnout. Journal of Psychosomatic Research, 56, 566 –567.
Grossi, G., Perski, A., Evengard, B., Blomkvist, V., & Orth-Gomer, K. (2003). Physiological correlates of burnout among women. Journal of Psychosomatic Research, 55, 309 –316.
Haverkampf, C. J. (2013). A Case of Burnout. J Psychiatry Psychotherapy Communication, 2(3), 80–87.
Haverkampf, C. J. (2017). Healing Burnout.
Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1–35.
Holsboer, F. (2001). Stress, hypercortisolism, and corticosteroid receptors in depression: Implications for therapy. Journal of Affective Disorders, 62, 77–91.
Houten, the Netherlands: Bohn, Stafleu, Van Loghum. Huibers, M. J. H., Beurskens, A. J. H. M., Prins, J. B., Kant, I., Bazelmans, E., van Schayck, C. P., et al. (2003). Fatigue, burnout, and chronic fatigue syndrome among employees on sick leave: Do attributions make the difference? Occupational and Environmental Medicine, 60, 26 –31.
Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397– 422.
McEwen, B.-S. (2000). Allostasis and allostatic load: Implications for neuropsychopharmacology. Neuropsychopharmacology, 22, 108–124.
Meijman, T. F., Thunnissen, M. J., & de Vries-Griever, A. G. (1990). The after-effects of a prolonged period of day-sleep on subjective sleep quality. Work & Stress, 4, 65–70.
Melamed, S., Ugarten, U., Shirom, A., Kahana, L., Lerman, Y., & Froom, P. (1999). Chronic burnout, somatic arousal, and elevated salivary cortisol levels. Journal of Psychosomatic Research, 46, 591–598.
Moch, S. L., Panz, V. R., Joffe, B. I., Havlik, I., & Moch, J. D. (2003). Longitudinal changes in pituitary-adrenal hormones in South African women with burnout. Endocrine, 21, 267–272.
Parker, A. J., Wessely, S., & Cleare, A. J. (2001). The neuroendocrinology of chronic fatigue syndrome and fibromyalgia. Psychological Medicine, 31, 1331–1345.
Pruessner, J. C., Hellhammer, D. H., & Kirschbaum, C. (1999). Burnout, perceived stress, and cortisol responses to awakening. Psychosomatic Medicine, 61, 197–204.
Pruessner, J. C., Wolf, O. T., Hellhammer, D. H., Buske Kirschbaum, A., von Auer, K., Jobst, S., et al. (1997). Free cortisol levels after awakening: A reliable biological marker for the assessment of adrenocortical activity. Life Sciences, 61, 2539 –2549.
Pruessner, M. M., Hellhammer, D. H., Pruessner, J. C., & Lupien, S. J. (2003). Self-reported depressive symptoms and stress levels in healthy young men: Associations with the cortisol response to awakening. Psychosomatic Medicine, 65, 92–99.
Raison, C. L., & Miller, A. H. (2003). When not enough is too much: The role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. American Journal of Psychiatry, 160, 1554 – 1565.
Roberts, A. D. L., Wessely, S., Chalder, T., Papadopoulos, A., & Cleare, A. J. (2004). Salivary cortisol response to awakening in chronic fatigue syndrome. British Journal of Psychiatry, 184, 136 –141.
Sapolsky, R. M., Romero, L. M., & Munck, A. U. (2000). How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. Endocrine reviews, 21, 55– 89.
Schmidt-Reinwald, A., Pruessner, J. C., Hellhammer, D. H., Federenko, I., Rohleder, N., Schurmeyer, T. H., & Kirschbaum, C. (1999). The cortisol response to awakening in relation to different challenge tests and a 12-hour cortisol rhythm. Life Sciences, 64, 1653–1680.
Schulz, P., Kirschbaum, C., Pruessner, J. C., & Hellhammer, D. H. (1998). Increased free cortisol secretion after awakening in chronically stressed individuals due to work overload. Stress Medicine, 14, 91–97.
Scott, L. V., & Dinan, T. G. (1998). Urinary free cortisol excretion in chronic fatigue syndrome, major depression, and in healthy volunteers. Journal of Affective Disorders, 47, 49 –54.
Steptoe, A., Cropley, M., Griffith, J., & Kirschbaum, C. (2000). Job strain and anger expression predict early morning elevations in salivary cortisol. Psychosomatic Medicine, 62, 286 –292.
Strickland, P., Morriss, R., Wearden, A., & Deakin, B. (1998). A comparison of salivary cortisol in chronic fatigue syndrome, community depression, and healthy controls. Journal of Affective Disorders, 47, 191– 194.
Theorell, T., Emdad, R., Arnetz, B., & Weingarten, A.-M. (2001). Employee effects of an educational program for managers at an insurance company. Psychosomatic Medicine, 63, 724 –733.
Wust, S., Federenko, I., Hellhammer, D. H., & Kirschbaum, C. (2000). Genetic factors, perceived chronic stress, and the free cortisol response to awakening. Psychoneuroendocrinology, 25, 707–720.
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.
Trademarks belong to their respective owners. No checks have been made.
© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved
Unauthorized reproduction and/or publication in any form is prohibited.