CC BY
21IRSTI 15.81.29, 15.81.61 DOI: 10.52512/2306-5079-2021-88-4-65-72
PHENOMENOLOGY OF BURNOUT SYNDROME A long journey from burning out to recovery
Petra Klastova Pappova
Paneuropean University, Bratislava, Slovakia petra.pappova@paneurouni .com
Abstract
While burnout syndrome has been by now frequently studied and described in literature, it has not been recognized as mental illness until now. The International Classification of Diseases 11th revision (ICD-11) includes the burnout syndrome in the category of occupational mental disorders. The present article describes the phenomenology of the burnout syndrome in order to demonstrate the complexity and length of treatment. Evolution of burnout syndrome and its individual stages described by Herbert J. Freudenberger are presented together with the three key dimensions of burnout by Christine Maslach. The treatment of burnout syndrome is often a lengthy and complex process. To illustrate this phenomenon, the author refers to her personal therapeutic experience with a group of clients diagnosed with burnout syndrome and subsequently undergoing individual psychotherapy in the form of Existential Analysis. As a psychotherapy method, Existential Analysis by Alfried Langle, works with the concept of four personal motivations as preconditions of a fulfilling life. Burnout syndrome is in this context understood as a loss of sense in an activity resulting from a long-term exhaustion.
Keywords: burnout syndrome, International Classification of Diseases 11th revision (ICD-11), phenomenology of burnout, treatment of burnout, individual psychotherapy, existential analysis, life values, meaning in life
Introduction
The aim of this paper is to provide an insight into the origins of burnout syndrome and its phenomenology. Reflecting the continuous progression of its symptoms and both mental and physical harm of burnout on individuals allows us to better understand the relatively long process of its treatment.
Burnout syndrome is a term associated primarily with activities and occupations which are challenging in terms of communication and require high levels of empathy and personal involvement. It can also gradually develop in professions in which a person's performance is subject to critical evaluation by others or where a person is exposed to chronic stress. Research over the past decades has shown that burnout has a multitude of negative health consequences for individuals, negative performance consequences for organizations and also society at large [1;2]. There currently exists neither an officially accepted definition nor a valid instrument for the differential diagnosis of burnout syndrome [2;781].
In 2021 Chloe Hiver, Antoine Villa et al. [3] carried out a systematic review and meta-analysis of studies regarding burnout prevalence among European physicians with the conclusion that medical community should determine a standardized method to assess burnout prevalence rates to best evaluate this phenomenon. Depending upon the study, physicians' burnout prevalence rates ranged from 2.5% to 72.0% [3].
Professionals in caring professions, especially medical staff, including psychologists, psychotherapists and social workers but also teachers, are at higher risk of developing burnout syndrome. However, the burnout syndrome can indeed occur in any profession or activity: managers, salespeople, women on maternity leave or performance-driven top athletes are also susceptible. Simply put, anyone who "burns with passion" in relation to an activity and / or is constantly overwhelmed by various demands at work, can literally "burn out".
Burnout syndrome is a state of physical, mental and emotional exhaustion. Physical symptoms include headaches, insomnia, indigestion or reduced immunity. There appears also chronic fatigue, feelings of loneliness and emptiness, as well as irritation simply at the thought of work or other relevant activity. People suffering from burnout may occasionally be cynical and overly critical of themselves and their surroundings, exhibiting little interest in others, manifesting a reduced creativity and diminished desire to work. Family, relationships and personal interests cease to be a source of joy or pleasure. Instead, these individuals tend to
experience a sense of failure, incompetence and helplessness. The risk of developing burnout increases with:
a. little or no control over the performance of one's occupation (workers with low decision-making power)
b. excessive or unclear performance requirements
c. lack of reward for well-executed tasks or quality work, lack of sense of accomplishment
d. excessive assumption of responsibility for others, inability to delegate tasks
e. perfectionism, the need to maintain control over others
f. stereotypical and unsatisfactory work
g. little time to rest and sleep
h. few close, supportive relationships
i. negative view of and little confidence in the world.
Materials and methods
The term burnout syndrome was coined by the American psychoanalyst and psychologist Herbert J. Freudenberger in 1974 [4;160]. Based on his research among health care professionals, he described the negative consequences of severe stress and high ideals found in helping and caring professions. Freudenberger found that medical doctors or nurses would often end up - after sacrificing for the good of their patients -exhausted, listless and unable to cope.
In his later work, Freudenberger described twelve stages of the burnout [5]. Individual stages may progress and develop linearly, but this is not always the case. Burnout would frequently manifest with regard to job or work, but later research showed that there may be multiple sources other than work, including benevolent activity, care of children or an ailing family member.
At present, the use of the term goes beyond the milieu of caring professions, and may describe any individual subject to severe stress, for example performance-oriented individuals such as managers, top athletes, celebrities but also overworked employees or housewives.
Building on the work of Freudenberger, American psychologists Christina Maslach and Susan E. Jackon further developed the concept of burnout, including the measurement and assessment of the degree of burnout. To this day, the Maslach Burnout Inventory is a widespread tool used to assess an individual's experience of burnout [6;100].
According to Maslach, the three key dimensions of developing burnout syndrome include (1) an overwhelming exhaustion,(2) feelings of cynicism and detachment from the job, and (3) a sense of ineffectiveness and lack of accomplishment [7;104].
Stages of burnout according to Freudenberger [5]
1. Compulsion / pressure to prove oneself
Arrival at a new job is usually accompanied by excitement, high ideals and desire to work. The individual sets about his responsibilities with a great drive, sets ambitious goals, and is eager to prove to himself and others that he can do what he may have had undertook.
2. Working harder
The individual is willing to take on new tasks, works overtime and takes responsibility over an increasing number of work activities. Work seems meaningful, the individual idealizes the sense and meaning of his efforts. The individual refuses to accept help from others as he feels he wants to 'pull it off himself. He expects recognition for his performance from his peers. The increased drive and the need for recognition start to take on the form of addiction. The individual loses his ability relax and rest.
3. Neglecting needs
As the individual is focused excessively on his work, he has little time or energy for other matters. He loses sight of his own needs and tends to neglect them. He starts to view the time spent with family or his hobbies, rest and sleep as useless and wasted because he could invest it to his job. Increased consumption of
food, coffee, cigarettes or alcohol may appear, as may sleep disorders and insomnia. The individual starts to be sensitive to criticism and remarks by his peers about his lifestyle.
4. Displacement of conflict
The individual usually understands that his way of operating is not good for him or his health. However, he is unable to see the real, underlying cause of his problem. He may become undisciplined, skips tasks, misses deadlines, promises things which he does not execute to the same standard as before. He may start to perceive his place of work, colleagues and superiors in a highly critical manner. He continues to neglect his hobbies, represses his own needs and finds himself increasingly with no energy to do things which brought him joy in the past. Sleep disorders, the feeling of weakness and exhaustion become increasingly pronounced. However, the individual does not admit that there is a problem to be addressed; instead, he tends to convince himself that there are still tasks here and there to be completed. In stages 3 and 4, the individual still wants to continue his highly-paced work style. There is a risk that addiction to alcohol, nicotine or other drugs may appear. The individual may start to eat excessively to release pressure, escape.
5. Change of values
The individual gradually isolates himself from others in order to avoid conflict. Increasingly, he suppresses his own needs. His values and life priorities change. Work-unrelated values become a burden, work is his only focus. He avoids individual contact; problems in family and in relationship appear. Friendships are under increasing stress and gradually end.
6. Denial of emerging problems
The consequences stress situations increasingly take their toll on family relationships and interpersonal relationships. Family and friends notice that the individual has changed and may be frequently intolerant, irritable, aggressive and is prone to outbursts. He may also hide anxiety, fear, inner tension and fatigue from his family because he does not want them to recommend that he changes his extreme work attitude. Stress at work creates stress at home and vice versa. The individual is increasingly negligent and his behaviour may become erratic. He may be late for meetings, and thinks of work with disgust mostly.
Between stages 6 and 7, the individual loses his relationship to work and files his 'inner resignation'. Expert assistance is required at this stage.
7. Withdrawal (from life and the world)
The individual loses his relationship to work, to his activities, life, ambitions and needs. He still tries to perform, however, his routines are mechanic, uninspired. He reschedules tasks for later. He feels emptiness and lack of meaning in life. He is looking for something meaningful, to occupy the vacated space of work. The risks of addictions, promiscuous behaviour in relationships increases. At this stage, the individual is unable to change his condition by himself. As regards his perceptions, the notion of I must dominates in all areas and a troubling sense of inner emptiness sets in. Psychosomatic disorders and other physical manifestations, resulting from increases tension and stress, appear.
8. Behavioral changes (dehumanization)
The individual's social life is further affected. He avoids others, withdraws and isolates. He experiences helplessness, self-pity, loneliness. He may frequently develop a codependent relationship with colleague from his workplace. They may reinforce their sentiments about life around them, such as having a hard time at the work place or not being duly recognized for their work. However, they will respond to kindness with hostility and irritation. They disparage others and show cynicism.
In caring professions, dehumanization is an attendant phenomenon of burnout. A medical doctor suffering from burnout may not say 'I have many patients with bladder pain', instead, he will refer to his patients as 'bladders'. Similarly, a teacher will not say I have 30 students waiting for me, instead he may refer to them to as 'villains'. The individual may remain in this state for years, performing his tasks in a detached manner, with little concern for his clients, work, or himself as the person executing the task or work. By dehumanizing others, the individual protects himself from further burden or strain.
9. Depersonalization
The individual functions as if pre-programmed, he experiences inner emptiness and his relationship to himself is disturbed. Increasingly, he experiences psychosomatic disorders.
10. Inner emptiness
The individual almost completely loses his ability to experience joy. Instead, he feels inner emptiness with feelings of despair, anxiety, fear of others. He withdraws, adopts a negative approach to life, feels disgusted by himself or others; in the end, his disgust includes everything. He consumes alcohol, food immoderately, engages excessively in sex or bizarre sexual practices.
11. Depression (and exhaustion)
The individual is subject to strong depression and profound exhaustion. He typically desires to be left alone, and craves sleep. He experiences hopelessness and suicidal risk is high. At this stage, the individual considers the future is bleak and there is no way out. At this stage, the only recommended solution is to change jobs or the line work entirely.
12. Burnout
At this stage, the individual under serious threat at all levels and may be prone to physical, cognitive and immunity collapse. Absolute exhaustion may lead the individual to total physical collapse and death.
Differences between burnout and depression
In general, certain symptoms considered typical for burnout also appear in depression, making a rapid and reliable differentiation between the two rather challenging. The overlapping symptoms may include extreme exhaustion, feeling down (depressed), listlessness, inability to cope, withdrawal and reduced performance. Schonfeld and Bianchi suggest replacing the notion of burnout with the concept of job-induced depression [8;1455].
However, there are important differences between the burnout and depression. For example, while burnout tends to be related - at least in the early stage - to a specific activity or work, depression induces a comprehensive withdrawal from daily activities and manifests as an inability to experience joy in any area of life. Furthermore, while burnout would typically cause inability to fall asleep or to "switch-off, as well as disturbed sleeping pattern, depression causes individuals to wake up early or experience morning pessimum.
Treatment of burnout syndrome
To successfully treat burnout we need to understand its causes, manifestation of symptoms in particular stages and the overall phenomenology of the syndrome. Treatment and eventual overcoming of burnout depends on the stage to which it progressed. Treatment in initial stages tends to be less complicated; however, it is still a relatively lengthy process. Author's therapeutic experience shows that an advanced burnout syndrome requires at least several months' sick-leave, in many cases clients may be unable to return to work for a year or even longer. Absence of treatment or attempts to repress the presence of exhaustion and fatigue can have serious health consequences. Convalescence is often challenging, even if combined with other interventions such as effective psychotherapy, pharmacotherapy (antidepressants), relaxation, calming activities and plenty of rest.
Burnout syndrome in international classification
While burnout syndrome has been by now frequently studied and described in literature, there currently exists neither an officially accepted definition nor a valid instrument for a differential diagnosis of burnout syndrome. It is generally considered that its key manifestations are related to three dimensions: emotional exhaustion, depersonalization, and reduced performance and/or motivation. Consequently, burnout syndrome
has not yet been precisely defined in international classification systems. For example, burnout is not recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th revision (DSM-5) [9].
In diagnostics of mental disorders, the Slovak Republic applies the International Classification of Diseases, 10th revision (ICD-10). Burnout syndrome is included in category Z73 Problems related to difficulties in coping with life, coded as Z73.0 total exhaustion (burn-out) [10;765]. However, diagnoses in category Z do not indicate presence of a disorder per se, rather, they denote a so-called related conditions or examination. Individuals suffering from burnout are often diagnosed with depression, exhaustion syndrome or similar conditions. Of note, ICD 11th revision (ICD-11) does include burnout syndrome among occupation-related mental disorders (ICD-11 for Mortality and Morbidity Statistics) [11;1].
In 2018, the Office of the European Union (EU) published a comprehensive review of burnout in the workplace. The results indicate that responses to burnout in EU member states can be found under different policy headings, such as stress at work, (excessive) working hours and mental health in the workplace, while burnout may also be included in national occupational safety and health strategies [12; 1].
As stated by Lastovkova et al., the lack of an official diagnosis of burnout limits the access to treatment, disability coverage, and suitable workplace arrangements [13; 164].
Results and discussion
Research sample
From 2014 to 2016, the author worked in Belgium as a clinical psychologist and psychotherapist in own practice. Her clients included, for the most part, individuals working for the European Commission (EC). EC's health care system does recognize burnout syndrome as a diagnosis. Therefore, employees diagnosed as suffering from burnout can be put on sick leave.
Throughout the author's stay in Belgium, a total of 21 clients suffering from burnout followed a long term individual psychotherapy in her private practice. Burnout syndrome was officially diagnosed by a medical specialist, usually a psychiatrist. The sample group included 12 females and 9 males working for the EC for the most part. Table 1 includes division of clients by gender and age. Table 2 includes the division of clients by use of medication and duration of sick-leave caused by burnout syndrome.
Table 1
Clients by gender and age:
total % age group average
females 12 57,1 32-58 44
Males 9 42,9 38-56 42
total 21 100 32-56 43
Table 2
Clients by use of medication, sick-leave span and individual psychotherapy duration:
total on medication sick-leave span in months average sick-leave in months psychotherapy span in months average duration of psychotherapy in months
females 12 9 3-15 9 5-26 18
Males 9 6 4-16 10 7-22 14
total 21 15 3-16 10 5-26 16
Results
The aim of this overview is to illustrate, based on author's personal experience as a psychotherapist, the relatively long process from being diagnosed with burnout syndrome to at least partial recovery following medical and psychological treatment.
Of the total number of 12 females and 9 males diagnosed with burnout, 75% of females and 67% males were on medication (antidepressants). Average sick leave span was 9 months in females and 10 months in males. Average individual psychotherapy span was 18 months in females and 14 months in males. Clients continued their therapies following the improvement in symptoms and return to work. The health care system of the EC recognizes part-time sick leave, i.e. an individual can be recognized to be fit to work 20 %, 50 % or 75 % of the (full) time, while the increases in work load are gradual, subject to oversight by a medical specialist. The average sick leave span is given as the number of months at 100 % sick leave. All clients returned to work, subject to gradual increases in workload, as recommended by the supervising medical specialist.
This overview is based on the personal experience of the author, namely her work with clients diagnosed as suffering from burnout in the context of a system which recognized burnout as a diagnosis (under the European Commission health care system). The sample given herein is too small to serve as a basis for any far-reaching and definitive conclusions about the relations between the age, sex, presence of medication, span of sick leave and individual therapy. However, it includes different characteristics illustrating the fact that the treatment of burnout is time consuming.
In individual therapies, the author applied Alfried Langle's existential analysis [14;7]. Existential analysis uses the concept of four personal motivations as preconditions of a fulfilling and rewarding life [15;18]. Burnout syndrome is understood as a loss of sense in an activity resulting from a long-term exhaustion. An individual would neglect himself, his needs as well as those elements of his life which he may have considered valuable in the past. In therapies, the author and her clients would work together to seek and add new resources, to re-establish boundaries, and to strengthen the sense of one's own value/worth (to be recognized for what one is, irrespective of one's performance). Therapies also included work on values, i.e. identifying the values which clients considered as relevant, which they wanted to live and towards which they wanted to head in their lives. Existential analysis is based on the assumption that values in life are highly individual and it is through values that individuals realize the meaning in their lives. In other words, living our own values enables us to experience our life as meaningful and fulfilling.
Conclusions
It is the author's personal experience that there are many more clients who seek a psychotherapist because they suffered from burnout syndrome even without ever been diagnosed as such. Exclusion from the work is usually protracted and treatment is time consuming. A psychotherapist can address the burnout phenomenon itself; however, in terms of further care for the client and his well-being, a precise diagnosis is also needed to establish a clearer framework for treatment. In this regard, the inclusion of burnout in ICD-11 would appear as a useful and a necessary step forward.
The title of this article suggests that it is a long journey from burning out to recovery. Considering the course of burnout, as well as frequently serious consequences and the long duration of therapy, it indeed appears to be so.
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ЖАНУ СИНДРОМЫНЬЩ ФЕНОМЕНОЛОГИЯСЫ Кушп калудан сауьн^а дешнп ^зак жол
Петра Кластова - Паппова Панеуропальщ университет, Братислава, Словакия petra.pappova@paneurouni.com
Эмоционалды кYЙзелiс синдромы казiрri уакытта эдебиетте жиi зерттелш, сипатталганымен, ол элi кYнге дешн психикалык ауру ретiнде танылмады. 11-iншi кайта каралган аурулардын халыкаралык жiктелуi (ICD-11) эмоционалды кYЙзелiс синдромын кэаби психикалык б^зылулар санатына косады. Б^л макалада емдеудiн кYPделiлiгi мен узактыгын керсету Yшiн эмоционалды кYЙзелiс синдромынын феноменологиясы сипатталган. Дж. Герберт Фрейденбергер сипаттаган эмоционалды кYЙзелiс синдромынын эволюциясы жэне онын жеке кезендерi Кристина Маслахтын эмоционалды кYЙзелiсiнiн Yш непзп елшемiмен бiрге ^сынылган. КYЙiп калу синдромын емдеу кебiнесе ^зак жэне кYPделi процесс болып табылады. Б^л к¥былысты суреттеу Yшiн автор эмоционалды ^йзелк синдромы диагнозы койылган жэне кешннен экзистенциалды талдау тYрiнде жеке психотерапиядан еткен клиенттер тобымен езшщ жеке терапевтiк тэжiрибесiне сiлтеме жасайды. Психотерапия эдiсi ретiнде Альфред Ленгленщ экзистенциалды талдауы толыкканды емiрдiн алгышарттары ретiнде терт жеке
мотивация т^жырымдамасымен ж^мыс ютейдг Б^л KOHTeKCTeri эмоционалды кYЙзелiс синдромы узак; уакыт саркылу нэгижeсiндe ю-эрекеттщ магынасын жогалту деп гYсiнiлeдi.
Туйт свздер: эмоционалды куйзетс синдромы, 11 -iншi кайта карау ауруларынын хальщаральщ жiкгeлуi (ICD-11), эмоционалды кYЙзeлiс феноменологиясы, эмоционалды куйзетсп емдеу, жеке психотерапия, экзистенциалды талдау, вмiрлiк к^ВДыльщтар, вмiрдiн мэнi
ФЕНОМЕНОЛОГИЯ СИНДРОМА ЭМОЦИОНАЛЬНОГО ВЫГОРАНИЯ
Долгий путь от выгорания к выздоровлению
Петра Кластова - Паппова Паневропейский университет, Братислава, Словакия petra.pappova@paneurouni.com
Хотя синдром эмоционального выгорания к настоящее время подробно изучается и описывается в литературе, до сих пор он не признан психическим заболеванием. Международная классификация болезней 11-го пересмотра (МКБ-11) включает синдром эмоционального выгорания в категорию профессиональных психических расстройств. В настоящей статье описывается феноменология синдрома эмоционального выгорания, с целью продемонстрировать сложность и продолжительность лечения. Эволюция синдрома эмоционального выгорания и его отдельные стадии, описанные Гербертом Дж. Фрейденбергером представлены вместе с тремя ключевыми измерениями эмоционального выгорания Кристины Маслах. Лечение синдрома эмоционального выгорания часто является длительным и сложным процессом. Чтобы проиллюстрировать этот феномен, автор ссылается на свой личный терапевтический опыт с группой клиентов, у которых был диагностирован синдром эмоционального выгорания и которые впоследствии проходили индивидуальную психотерапию в форме Экзистенциального анализа. В качестве метода психотерапии Экзистенциальный анализ Альфреда Ленгле работает с концепцией четырех личных мотиваций как предпосылок полноценной жизни. Синдром эмоционального выгорания в этом контексте понимается как потеря смысла в деятельности в результате длительного истощения.
Ключевые слова: синдром эмоционального выгорания, Международная классификация болезней 11-го пересмотра (МКБ-11), феноменология эмоционального выгорания, лечение эмоционального выгорания, индивидуальная психотерапия, экзистенциальный анализ, жизненные ценности, смысл жизни
ИНФОРМАЦИЯ ОБ АВТОРЕ
Петра Кластова-Паппова, PhD, доктор философии, кафедра клинической психологии, факультет психологии, Паневропейский университет. Адрес: ул. Томашикова 20, 820 09 Братислава, Словацкая Республика; ORCID ID 0000-0001-6399-6093; petra.pappova@paneurouni.com
АВТОР ТУРАЛЫ АППАРАТ
Петра Кластова-Паппова, PhD, философия докторы, клиникальщ психология кафедрасы, психология факультет^ Панеуропальщ университет. Мекен жайы: Томашиков кэшей, 20, 820 09 Братислава, Словакия Республикасы; ORCID ID 0000-0001-6399-6093; petra.pappova@paneurouni.com
INFORMATION ABOUT THE AUTHOR
Petra Klastova Pappova, PhD, PhDr., Department of Clinical Psychology, Faculty of Psychology, Paneuropean University. Address: Tomasikova 20, 820 09 Bratislava, Slovak Republic; ORCID ID 0000-0001-6399-6093; petra.pappova@paneurouni.com
Редакцияга тусп / Поступила в редакцию / Received 06.12.2021 Жариялауга кабылданды / Принята к публикации / Accepted 24.12.2021
