Challenges to Therapist Self-Care with In-Home Work

Module Sections:


Welcome to the Self-Care Course


Self-care entails both a personal and professional developmental process. A person's needs change through maturity and, it follows, that the self-care needs change as well. This module is focused on explaining the various components of clinician self-care practices, especially as they relate to therapeutic work in various home environments.

Providing therapy can be demanding and complicated work. When considering the provision of services in the home environment, the demands and impact upon the therapist become more complex simply because of the nature of home-based work. While many home-based clinicians value the home environment, it nonetheless, contributes an additional set of stressors. This module will ask you to think about your own stressors and self-care program. Concepts and frameworks are provided to guide your thinking process. We encourage you to use your journal to reflect upon the information provided especially as it pertains to you personally.

The structure of this module will guide your exploration of applicable, personal self-care issues through:

  1. Establishing a common ground of terminology and interacting with a therapist vignette
  2. Developing a unifying framework for exploring the role of self-care throughout the process of therapy
  3. Applying a personal self-care framework through a clinical example. This clinical example is therapist focused, not client focused
  4. Creating a journal of your personal responses and reflections
  5. Creating a personal self-care program for you to integrate into your daily living

Module Objectives

Through this module you will be able to:

  • Identify personal self-care issues that need to be addressed in your life and clinical practice
  • Utilize a unifying framework to examine your own self-care
  • Assess areas of your practice and life that contribute to personal or professional self-awareness regarding stress and self-care
  • Identify personal cases that have the potential to stir feelings of countertransference
  • Identify self-care techniques, that other clinicians have found useful, and integrate them into your therapeutic practice
  • Develop your own program of self-care that will lead to increased balance for both your personal and professional life

Scope of the Issue

The multidisciplinary, behavioral sciences literature often suggests that psychotherapist self- care is an essential element for providing effective clinical services to those with mental health needs (Baker, 2003; Lonergan et al., 2004). If behavioral science practitioners want to continue providing effective clinical services, an emphasis on self-care is necessary for preventing or minimizing therapist burnout.

Depression is the most prevalent symptom of clinicians experiencing professional distress. Approximately two-thirds of therapists have experienced at least one episode of depression (Gilroy, Carroll, & Murra, 2002). A former study by the same authors (Gilroy, Carroll, & Murra, 2001) discovered that 76% of the female therapists in their sample were experiencing dysthymia. Gilroy, Carroll, and Murra (2002) note that previous studies have determined that depressive symptoms significantly impact a clinician's professional functioning. The "detrimental consequences include: inability to maintain a focus with clients, memory problems, fatigue, lack of energy and motivation for therapeutic work… and can potentially lead to more serious signs of impairment, including boundary and other ethical violations." (p.402) Furthermore, clients notice when a clinician experiences the progressive effects of burnout. McCarthy and Frieze (1999) studied clients who reported perceiving their therapist as experiencing "burnout". The clients generally report receiving sub-par services and may experience negative outcomes from therapy. They discovered that "participants' perceptions of their therapists' effectiveness, their satisfaction with the therapeutic relationship, and their overall impression of the successfulness (sic) of therapy were related in predicted ways to their reports of therapist… burnout." (pp. 46-47)

While a therapist's burnout impacts the therapy process, Bakker & Schaufeli (2001) noted that the therapist's burnout also has an impact on colleagues with whom he/she works. They discovered that burnout has a contagious effect on others in an organization. They describe the effect as a "staff infection" where "human service professionals may 'catch' the negative feelings, the cynical attitudes, or impaired job behaviors of their colleagues." (p. 92) Given this result, there are many ethical implications for a therapist's use of self-care for maintaining or improving personal as well as professional functioning and collegial relationships.

Ironically, many graduate programs tout the importance of preventative measures and exercises against therapist burnout (Lonergan et al., 2004). However, contrary to recommendations to prioritize therapist self-care, the literature states that there is a paucity of research and focus on self-care in the behavioral sciences across the many disciplines. This module addresses this important issue and will provide you with a framework for understanding the importance of developing and utilizing a self-care program. Specific suggestions will help you to develop a program that encompasses several activities that have been purposefully chosen, prioritized, and integrated in your daily schedule. Furthermore, suggestions will be offered for developing collegial relationships mutually supportive of therapist self-care.


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Establishing a Common Ground

What is Self-Care?

John Norcross, an avid self-care researcher and presenter, stated, "I am not certain that I have a definition of self-care, truth be told" (Personal Communication, 2006). Though a working definition of self-care may be elusive, it is often approached by integrating the following elements of a clinician's experience: physical, cognitive, emotional, relational, recreational and spiritual (Faunce, 1990; Moursund, 1993; Porter, 1995, as cited in Carroll et al.,1999). The four areas of a clinician's personal and professional self-care include, but are not limited to (Carroll et al., 1999):

Intrapersonal work—the things done to help clarify your view of yourself as an adult and/or a clinician.

Interpersonal support—receiving help and support from others, especially friends and family

Professional development and support—attending continuing education workshops and conferences, and receiving support from colleagues and supervisors

Physical and recreational activities (Leisure)—time spent engaging in hobbies and activities that refresh, rejuvenate and invigorate the mind and body

Personal and Professional Self-Care

The term "self-care" may mean something different for each practitioner. What may constitute self-care for one clinician may not be helpful to another. However, it is important to remember that self-care is one of the five virtues (beneficence, nonmalfeasance, fidelity, justice and self-care) underlying mental health professionals codes of ethics. For this reason, we will explore the many forms and types of self-care, as outlined in the literature. You will have the opportunity to reflect upon various aspects of self-care, including how you have personally and professionally been able to exercise and implement specific strategies. In addition, you will have the opportunity to discuss your thoughts and strategies surrounding self-care with other clinicians around the state of Kansas. With this opportunity you may discover new ways to use and implement self-care regimens in your daily life. This is the start of developing a program of self-care.

Kramen-Kahn & Downing Hansen, (1998) citing information from Coster & Schwebel (1997) state: "on any given day, (practitioners) try to serve client needs, maintain an ethical practice, manage increasing paperwork and bureaucracy, stay informed about new interventions and specialties, foresee how emerging changes in the health care environment will affect them, market their services, and defend the efficacy of their interventions." (p. 130 ) These demands may lead the clinician to consider how to cope with the job responsibilities that effectively maintains a healthy personal life. It is with this in mind that the following outline of the forms of professional and personal self-care is provided. As Norcross & Guy (2007) have emphasized, the premise of self-care involves valuing the person of the therapist. As the various forms of self-care are outlined, it will be important to reflect upon how you integrate each of these into your developing program of self-care.

Personal Values & Balanced Lifestyle

Adhering to Personal Values

  • When professional psychologists were asked what was paramount to their well-functioning, "personal values" was among their top 29 answers. "(They) equated 'personal values' with those things or principles important to (them) that guide (their) behavior" (Coster & Schwebel, 1997). There are times in clinical work when we may feel our personal values are being challenged/assaulted by the information the client is providing or even the expectations from working in a managed care setting.
  • Reflection: When your personal values are challenged professionally, how do you maintain your professional relationship? How does your awareness of your personal values help you to respect the clients' personal values while working in their home?

Maintaining a Balanced Lifestyle

Tippany et al. (2004) asserted that maintaining a balance between one's personal and professional life is essential in maintaining one's self-schema. Minimizing the negative impact of exposure to the traumatic stories of others, also referred to as vicarious traumatization, arises from being exposed to the continual work with clients' descriptions of personal traumas, problems, or issues.

  • Reflection: What are some indicators within your experiences that signal when your lifestyle is getting "out of balance"? How does the reduced balance impact your clinical work?

Interpersonal Support

Interpersonal Support (Carroll et al, 1999)

  • Interpersonal relationships, both professional and personal, focused on maintaining healthy, vibrant connections with others may sustain, renew, and enrich the counselor (Myer & Ponton, 2006). Healthy, supportive relationships within and outside of the office are critical to reconnecting the home-based therapist to experiences beyond the therapeutic process.

Friendships, Relationships, Humor


  • Each support network forms a barrier against the counselor's stresses, thus providing protection from possible impairment (Witmer & Young, 1996). Positive social support is a factor that positively correlates with protection against a therapist's tendency to internalize the negativity that may accompany a caseload with high intensity and high trauma issues. It seems that regardless of the profession, time away from the demands of work is essential to relieving stress and preventing burnout or impairment. Friendships within and outside of the work environment contribute to this sense of balance. Consider how easy it is to "talk shop" with colleagues outside of the work environment (The reference here assumes confidentiality is maintained for all clients.) regarding the stresses of the job. Having time to relax with colleagues is helpful to some clinicians. Others prefer to keep their professional and personal relationships separate and not develop friendships with colleagues outside of the office. As each therapist considers what is best for their own self-care, the critical point is to maintain healthy, supportive relationships inside and outside of the office.

Collegial Relationships

  • According to Reid et al. (1999), a study of 30 mental health professionals found that contact with colleagues was one of the major rewards of the job and acted as a buffer against stress. "Colleagues are pretty important in being able to sit down and say exactly how you are at the time when it's happening and it's nearly always possible to do that in the office..."(p. 310). Home-based therapists must be more creative regarding access to colleagues because of the lack of time spent in the office. It is, therefore, important for the HBFT clinician to actively seek out collegial support through ongoing discussions with supervisors, agency administrators, and fellow clinicians to create opportunities for accessing this support.
  • Reflection: How do your relationships balance the isolation factor of home-based work, (especially personal relationships)?

Sense of Humor

  • Using humor inside and outside of the office is often an effective way of reducing anxiety, frustration and stress. The levity of humor provides a temporary respite from stress and establishes a connection with others.
  • Reflection: Think about one way you involve humor in your work environment and its impact upon you and the others around you.

Professional Development & Support

Professional Development and Support (Carroll et al., 1999)

Using Case Consultation/Supervision

  • The use of colleagues for case consultation, particularly to maintain objectivity about clients and to sustain interest in their problems is necessary and helpful (Kramen-Khan & Hansen, 1998). Collaborating with colleagues may provide a sense of support for the clinician's ideas while also contributing to the development of additional areas of focus and intervention. Colleagues may provide validation for intuitive concerns about safety, risk, and a clinician's emotional reaction to the family environment or disclosure of information. Supervision is essential for the home-based therapist in managing appropriate boundaries, accessing available resources, receiving guidance and support, and simultaneously maintaining varying points of view.
  • There is a strong connection between supervision and self-care. Clinicians who are able to co-create a relationship that involves vulnerability with their supervisor will feel more comfortable discussing self-care issues. Littell and Tajima (2000, as cited in Lawson, 2005) found that "adequate and quality supervision was positively correlated with collaboration and compliance characteristics in families; negative correlation between supervision and a deficit orientation in the counselor." As the supervision process addresses the clinician's case-by-case needs and makes self-care a priority, the clinician is then encouraged to prioritize self-care as well.

Development & Support Tools

Scheduling breaks

  • Taking time to unwind and collect one's thoughts between sessions, and occasionally during sessions, is often helpful in preventing clinician burnout. The home-based therapist may consider accessing areas within the community to engage in self-reflection between sessions. This self-reflection will also be valuable to the supervision process.

Attending continuing education seminars

  • Continuing education is also recommended to maintain and expand one's therapeutic skills, while also nurturing one's overall interpersonal support (Kramen-Khan & Hansen, 1998) through collegial relationships. As the clinician expands knowledge, skills and awareness of professional issues, the clinician is also better prepared to address the expressed needs of the client.

Monitoring caseloads

  • Caseload management is an area specifically connected to therapist self-care. When a home-based clinician is faced with large caseloads and a number of high intensity cases, self-care can easily be perceived as another burden. The process of monitoring caseloads is particularly relevant to the supervision process and maintaining ongoing collaborative discussions about the clinician's daily responsibilities.

Setting realistic expectations

  • Unrealistic therapeutic goals, expectations, and loosely established guidelines for evaluating progress may interfere with therapeutic efficacy and lead to lower morale (Kestnbaum, 1984). Each clinician must realistically determine that the therapeutic goals and expectations are manageable within the timeframe and context of the therapy process. For the home-based therapist, consideration must also be given to the logistics of the service (e.g. distance to home of each case).
  • Reflection: What additional methods do you draw on for your professional development and support? What is one aspect of supervision that contributes to you feeling supported?

Physical & Recreational Activities

Physical & recreational activities (Carroll et al., 1999)

Diet and regular exercise

  • Each reduces anxiety and supports better overall well being and health. The home-based therapist may be eating on the road or involved in environments that may be less than healthy exposing the clinician to diseases or illness not experienced by the office-based therapist. Developing diet and exercise regimens based upon prevention as well as a response to stress are essential.


  • Taking time to read something other than work-related texts can often be a way to take care of oneself and leave the professional world behind for the moment.


  • Activities like gardening, collecting stamps, etc. help to set boundaries between work and one's personal life.

Recreational vacations

  • Kramen-Khan & Hansen (1998) stated: "Practicing what we, as clinicians, often preach to clients about prioritizing leisure activities will help create a renewing balance between work and play" (p. 133).
  • Reflection: As you consider the intrapersonal, interpersonal, professional development, and physical aspects of self-care, which appears to be a priority?

Continuum of Therapist Self-Care

To explore personal levels of stress we suggest using the framework from the Multidimensional Model of Cultural Competence (Sue & Sue, 2003). Developed to examine levels of counselor cultural competence, this model provides a useful framework involving the awareness, knowledge and skills that are necessary for continued improvement of clinical competence. The areas of this framework provide guidance for thinking about areas of our professional and personal lives that may be easily forgotten or ignored.

The following continuum illustrates the correlation between a therapist's level of stress and the types of efforts that are used to address that stress. Moving toward the right along the continuum reflects a therapist's experiences of stress as increasingly unmanageable. HBFT therapists face additional stressors related to safety concerns and feelings of isolation experienced with doing therapy in the home. Separation from the ongoing collegial and supervisory support, more readily available in an office-based setting, requires additional self-care efforts that address these deficits. Consequently, the efforts to relieve the stress increasingly reflects the use of reactive and, eventually, remedial strategies. Conversely, moving toward the left along the continuum suggests that a therapist is using a self-care program that incorporates more preventative measures for handling stress and more likely perceives the unique home-based stressors as manageable.

Figure 1. (Sue & Sue, 2003) Managed Stress - Unmanaged StressFigure 1. (Sue & Sue, 2003)

Unmanaged stress in the absence of a self-care plan or program, often leads to reactive efforts that may or may not moderate or resolve the stress. Increasing unmanaged stress eventually results in burnout. Somewhere between reactive and remedial efforts reflects a theoretical point where unethical behaviors compromise professional integrity and inhibit therapy progress. Increasing unmanaged stress reaches a point where the clinician's judgment and resulting actions are severely compromised. Approaching beyond this point there is an increasing impact on client safety and quality of care. Clinicians who have developed a dual relationship, engaged in sexual relationships, or neglected a client would be identified at this end of the continuum. If a clinician engages in unethical behaviors, remedial measures would be required to reestablish ethical practice.

Movement toward the left of the continuum requires an enhanced self-care program. Consider the following concepts as a guide to reviewing your level of stress and your attempts to address that stress:

Improving awareness

  • Examine your own level of stress and its possible impact on your ability to provide effective therapeutic care.

Building knowledge

  • Your involvement with this module, access to the available literature, and consultations with your supervisor and colleagues can help to build your knowledge of the factors that impact your levels of stress. Additional knowledge can also improve awareness of the available strategies for appropriately handling stress.

Developing skills

  • Establish specific ways to include self-care into your daily schedule. Use your collegial and supervisory supports to improve the accountability for making self-care a priority and determining its effectiveness.

Therapist Stress & Burnout


Occupational stress results from an imbalance between occupational demands and available coping resources (Maslach et al., 1996). Therapist caseloads, administrative responsibilities, and supervisory resources each contribute to added stress. When a therapist experiences these as usurping one's own sense of control, he/she may feel helpless and disempowered from making any changes.


Compassion fatigue, vicarious traumatization, secondary traumatization, secondary traumatic stress, secondary victimization (Figley, 2002) result from repeated exposure to clients' traumatic stories. This exposure can alter a person's perception of basic psychological needs, such as those for safety, trust in self and others, esteem for self and others, intimacy, and control (Trippany et al., 2004). Gilroy, Carroll, & Murra (2002) note, "The increasing attention in the professional literature to issues of secondary trauma (Cerney, 1995) and vicarious traumatization (McCann & Pearlman, 1990; Pearlman & MacIan, 1995) has, for example, served to heighten our consciousness about the potential negative impact that [practicing] psychotherapy can have on clinicians" (p. 406).

Burnout is related to a clinician's degree of self-efficacy and satisfaction association with therapy roles and responsibilities. Burnout can result from a clinician's efforts to address issues and challenges that arise in the course of accomplishing the work. Through a gradual onset, clinicians experience burnout after repeated inadequate attempts to address stress that has accumulated, or piled up, over time. The culmination of the stress leads to the following constellation of factors:

  • Emotional exhaustion - The concept of burnout integrates exhaustion with staff members' involvement in their work, especially the people with whom they work, and their sense of efficacy or accomplishment (Cushway et al., 1996)
  • Depersonalization – Refers to an impersonal and dehumanized perception of recipients, characterized by a callous, negative, and detached attitude (Salanova et al. 2005)
  • Reduced/Lack of personal accomplishment – The tendency to evaluate one's work with recipients negatively (Salanova et al. 2005)
  • Negative self-concept - Feelings of decreased sense of self-worth and diminished self-esteem, which may lead to self-defeating behavior
  • Cynicism and negative job attitudes-Resulting from seeing one's job in a negative light and wondering if the career was a bad fit, where one used to enjoy their work

Therapist Experience of Burnout

The following list provides examples of the emotional, psychological, and behavioral indicators of burnout:

Emotional Indicators (As cited in Rosenberg et al., 2006)

  • Boredom, cynicism, anxiety, withdrawal (Friedman, 1985)
  • Irritability, loss of morale, feelings of isolation (Jayaratne & Chess, 1984)
  • Psychological numbing
  • Feelings of hopelessness, futility, and despair (Kestnbaum, 1984)
  • Depression and suicidal ideation (Piercy & Wetchler, 1987)

Psychological Indicators

  • Distractibility
  • Memory problems
  • Concentration problems

Behavioral Indicators

  • Isolating from others
  • Avoidance of those with similar issues

Building Personal Awareness

The following three self-assessments are available for you to build greater awareness of your current well-being and the level of distress that you may be experiencing as a result of your work. The first self-assessment asks basic questions to screen for advancing to the subsequent assessments. If you answer yes to these initial questions, then we suggest that you use the following assessments to explore your experience in more detail.

Brief Screening

Please take some time now to briefly ask yourself the following questions:

  1. How do you know if you are approaching burnout?
    • Are you experiencing any of the following therapeutic warning signs of burnout:
    • Are you feeling numb?
    • Do you find yourself irritated by certain clients who were not previously annoying?
  2. Are you battling depression or dysthymia that is exacerbated by or influencing your clinical work?
  3. How do you remedy your own stress and possible burnout?

Self-Assessment Questionnaires (Barnett, Johnson, & Hillard, 2005)

This is another brief screening tool Self-Assessment Questionnaire that can enable you to examine possible signs and symptoms of distress, burnout and impairment. Additional questions help the clinician to identify positive and negative coping behaviors he or she is using to address those issues.

Professional Quality of Life (Pro-QOL) (Stamm, 2002)

This is a more extensive therapist self-assessment measuring the following domains of experience:

  • Compassion satisfaction – questions in this domain measure your level of satisfaction and fulfillment associated with providing assistance and support to others.
  • Burnout– questions in this domain measure the degree of work-related burnout.
  • Compassion Fatigue/Secondary Trauma – questions in this domain measure the degree to which your exposure and work with those reporting their traumatic stories has had a traumatic effect upon you.


Reexamine the assessment results and determine levels of stress and the types of self-care you use.

The purpose of this module is to assist you in moving further to the left along the continuum. The role of self-care is designed to manage levels of stress along the continuum. Notice that increasing utilization of preventative self-care measures will move you to the left toward the experience of managed stress. Sustainable, preventative measures suggest that self-care goals, strategies, and techniques are focused on the development and implementation of a program of self-care. A program of self-care differs from a self-care activity in that a program suggests engagement in ongoing, intentional, planned, and prioritized efforts that are integrated throughout your daily schedule. When a clinician makes decisions, self-care considerations are integrated throughout the initial considerations and schedule adaptations. If something comes up conflicting with the plan, self-care takes priority rather than being dropped from the schedule.

Self-Assessment & Pro-QOL

Self-Assessment Questionnaires (Barnett, Johnson, & Hillard, 2005)

This is another brief screening tool [link to PDF] that can enable you to examine possible signs and symptoms of distress, burnout and impairment. Additional questions help the clinician to identify positive and negative coping behaviors he or she is using to address those issues.

Professional Quality of Life (Pro-QOL) [link to PDF] (Stamm, 2002)

This is a more extensive therapist self-assessment measuring the following domains of experience:

  • Compassion satisfaction – questions in this domain measure your level of satisfaction and fulfillment associated with providing assistance and support to others.
  • Burnout– questions in this domain measure the degree of work-related burnout.
  • Compassion Fatigue/Secondary Trauma – questions in this domain measure the degree to which your exposure and work with those reporting their traumatic stories has had a traumatic effect upon you.

Reexamine the assessment results and determine levels of stress and the types of self-care you use.


Where are you located along the following continuum?

The purpose of this module is to assist you in moving further to the left along the continuum. The role of self-care is designed to manage levels of stress along the continuum. Notice that by increasing utilization of preventative self-care measures you will move to the left toward the experience of managed stress. Sustainable, preventative measures suggest that self-care goals, strategies, and techniques are focused on the development and implementation of a program of self-care. A program of self-care differs from a self-care activity in that a program suggests engagement in ongoing, intentional, planned, and prioritized efforts that are integrated throughout your daily schedule. When a clinician makes decisions, self-care considerations are integrated throughout the initial considerations and schedule adaptations. If something comes up conflicting with the plan, self-care takes priority rather than being dropped from the schedule.

Introduction & Model One

In conceptualizing the multiple ways clinician self-care, or lack thereof, can affect the practitioner, an attempt was made to find models that encompassed the multiple variables and complexity often associated with self-care practices. The ABC-X Model will be introduced to reflect variables associated with stress, including perceptions and resources. Boss' Contextual ABC-X model expands upon the original model to include coping and adaptation that exist beyond the crisis event. This model provides a focus for discussing the components incorporated within a clinician's self-care strategies. While the Boss' model provides a framework for examining a clinician's experiences and responses to stress and potential crises, an additional framework is needed to address stress that appears in the form of therapist burnout. Further research revealed two additional models that address the effects of burnout within organizational contexts: the Leiter Model (Leiter, 1991) and the Burnout Contagion Model (Bakker et al., 2001). A unified framework, informing the application of clinician self-care throughout the work of therapy, will be discussed in the next section.

Model One: Double ABC-X Stress Model – Individual in Family and other Contexts

The ABC-X Model was originally developed to address the social stresses on the family (Hill, 1958). This model illustrates the interplay between the following variables:

A (stressor—event or situation) B (existing resources) C (perception of stressor or resources) X (degree of the crisis resulting from interplay between A, B, and C).

Figure 3. (Hill, 1958)Figure 3. (Hill, 1958)

McCubbin & Patterson ABC-X Model

In fact, according to McCubbin and Patterson (1985), the ABC-X formulation has withstood careful assessment and has remained virtually unchanged from its initial inception in 1958. However, McCubbin and Patterson (1985) noted that, depending upon a person's coping abilities, there is the potential for the pile up of stressors and additional crises beyond the initial event.

Figure 4. (McCubbin & Patterson, 1985)Figure 4. (McCubbin & Patterson, 1985)

Further examination of the Double ABC-X Model reveals that the variables related to the stresses or crises affecting family systems are applicable to clinicians' personal and professional lives. The module variables are, more specifically, relevant for describing the factors influencing clinician self-care and stressors resulting from home-based family therapy. While therapy conducted within the office is somewhat controlled and in an environment well known by the therapist, seeing clients in their homes adds another level of complexity that has a stress-producing effect on the home-based family therapist. Possible stressors from the home environment can include: chaos within the home environment (i.e., lack of rules or boundaries, TV on, phone ringing, being the guest); friends and neighbors stopping by unannounced; lack of cleanliness; threats from various types animals; or client absent when therapist arrives.

Boss ABC-X Model

Boss' (2006) contextual model simplifies the original model while adding the contextual components that impact a person's stress management. With a focus on a person's internal and external contexts, Boss reminds us that personal and relational contexts influence and inform a person's thinking, decision-making, and behavioral responses.

Figure 5. (Boss, 2006)Figure 5. (Boss, 2006)

Model Two: Leiter Model

Individual and Agency Policies and Procedures

The Leiter Model predicts the potential burnout associated with an individual's coping patterns and the function of organizational demands and resources. The aspects of burnout include: emotional exhaustion, depersonalization, and diminished personal accomplishment, which are all placed in the center of the model. Emotional exhaustion is defined as the "emotional reactions to the stress and tedium a person is experiencing in a human service occupation" (Leiter, 1991 p. 124). Depersonalization is an individual's "unfeeling and callous response toward people who are usually the recipients of one's service or care" (Leiter, 1991, p. 124). Leiter (1991) defines diminished personal accomplishment as "a decline in one's feelings of competence and successful achievement in one's work with people" (p. 124).

Model Two: Leiter ModelModel Two: Leiter Model

Leiter Model Explanation

The way an individual copes with organizational stress determines whether or not they will experience the elements of burnout. Organizational stressors include: work overload and interpersonal conflict. The two types of coping patterns that clinicians can use to handle stress are control coping and escapist coping. Latack (1986, as cited in Leiter, 1991) defines control coping as "consisting of actions and cognitive reappraisals that are proactive, take-charge in tone; and escapist [coping] as consisting of both actions and cognitive reappraisals that suggest an escapist, avoidance mode" (p. 378). Control coping results in lower levels of overall burnout while escapist coping is associated with higher levels of exhaustion and depersonalization. Within the Leiter Model, other variables that affect burnout include: coworker support, skill utilization, and supervisor support, classified as organizational supports. These variables can affect all three levels of burnout which, in turn, can have an effect on a person's organizational commitment.

The Leiter Model explains the extent to which control coping and escapist coping contributes to the prediction of burnout. According to the study that produced this model, escapist coping can actually be associated with higher levels of exhaustion, and is ineffective in avoiding burnout. Since escapist coping can increase levels of exhaustion, this coping method and its patterns should be avoided. On the other hand, control coping is a better way of avoiding emotional exhaustion. For example, this method of coping is a more effective way of addressing stressors because, according to Leiter (1991), control coping and burnout appear to be inversely related—as one increases, the other decreases.

Leiter (1991) concludes that there are three distinct ways in which control coping can prevent burnout by:

  1. Increasing an individual's capacity to deal with stressful situations
  2. Contributing to a person's increased self-efficacy within his/her work environment
  3. Increasing self-appraisal and efficiency consistent with the individual's values.

Model Three: Burnout Contagion

Individual and Collegial Relationships

At the core of the Burnout Contagion Model are two variables: emotional exhaustion and negative work-related attitudes. This model is centered around the notion that negative work-related attitudes are "contagious" (Bakker, et al. 2001) and have a deleterious effect on individual workers. This means that when colleagues have "negative feelings, cynical attitudes, or impaired job behaviors," this can have an effect on their co-workers, who in turn, may develop symptoms of burnout.

Figure 7. (Bakker et al., 2001)Figure 7. (Bakker et al., 2001)

Bakker, et al. (2001) defines burnout as a reaction to occupational stress due to demanding and highly emotional relationships between human service professionals and their clients. In this model, emotional exhaustion or energy depletion is considered the core symptom of burnout. The Burnout Contagion Model depicts a relationship between emotional exhaustion and emotional contagion. Emotional contagion is defined as an individual's tendency to mimic another person's "facial expressions, vocalizations, postures, and movements" which results in the individual converging emotionally (Bakker, 2001 pg. 84). Therefore, the negative attitudes and behaviors of some can impact the perceptions and behaviors of others, even leading to burnout.

Forming a Unified Framework

ABC-X Model

The Contextual ABC-X Model offers the following variables to provide a general explanation of stress and coping—resources, perceptions and adaptation within varying contexts. The Leiter model focuses our attention on work-related stress that results in burnout. This model contributes the following variables: emotional exhaustion, depersonalization, and personal accomplishment and the two coping styles clinicians employ to address burnout: control coping and escape coping. Finally, the Burnout Contagion Model contributes one more variable: emotional contagion that leads to exhaustion. The emotional contagion variable suggests that burnout is experienced and shared within the work environment of human service professionals.

To review, each of the aforementioned models brings with them various definitions and variables. For example, each model discusses various types of stressors. The ABC-X Model (Hill, 1952) uses the term "stressor" to describe various situations that try a family or individual. According to the McCubbin et al. (1980), stress is also defined as a stimulus, and inferred inner state, and an observable response to a stimulus or situation. The Leiter Model (Leiter, 1991) includes "organizational stressors" which are work overload and interpersonal conflict. According to this model other stressors can include: the lack of or overuse of coworker support, skill utilization, and supervisor support. Within the Bakker et al. (2001) Burnout Contagion Model, an example of a stressor would be burnout complaints in colleagues, which is a form of negative emotional contagion.

Integrated ABC-X Model of Burnout

Each of these models offers unique ways of looking at processes around stress, burnout, and emotional contagion. However, one model by itself does not capture the way that these elements can be viewed as a whole. For example, the ABC-X Model does not explain the phenomena of emotional contagion by itself, nor does the Leiter Model. Similarly, the Burnout Contagion Model does not specifically address the variables found in the ABC-X or Double ABC-X Models—A (stressor), B (resources), C (perceptions), X (crisis) or Double A (stressor pileup), Double B (ways of coping), and Double C (perceptions of initial stressor or perception of stress or crisis). It appears that each model by itself lacks helpful explanations afforded by another modality. Therefore, these three models together help to contribute variables to the overarching view of the processes surrounding the three core (while the others are important too) variables affecting self-care:

  1. Emotional contagion
  2. Emotional exhaustion
  3. Burnout

An explanation is now given for how these three models have been joined to better explain the processes surrounding burnout. The marriage of these three models is referred to below as the "Integrated ABC-X Model of Burnout."

Integrated ABC-X Model of Burnout.Integrated ABC-X Model of Burnout.

Points of Integration

The Double ABC-X Model expanded on the general ABC-X Model by explaining what happens following a crisis (X), but for purposes of the Integrated ABC-X Model of Burnout (see Figure 8 above); the mal- and bonadaptation components of the Double ABC-X were removed. In their place were put the two types of coping found in the Leiter Model. In essence, "bon-and maladaptation" from the Double ABC-X Model were replaced with the Leiter Model terms of "escape" and "control" coping. Another important variable was added to the model—"emotional contagion." It is important to note that emotional contagion can be negative and positive in nature.

Using Strategies and Techniques

Awareness, Knowledge, Skills

The following strategies and techniques provide examples of ways you can improve your personal self-care program and, therefore, improve your clinical effectiveness:

Improving awareness

  • Awareness
  • Establish a baseline measuring your personal quality of life using ProQOL to determine levels of…
    • Compassion satisfaction
    • Burnout
    • Compassion fatigue/secondary trauma
  • Share the ProQOL with colleagues and share your results with each other

Building knowledge

  • Read articles and books that address ways to further your own self-care
  • Discuss themes from your readings with your colleagues while sharing self-care strategies that have worked

Developing skills

  • Take regularly scheduled breaks
  • Take regular vacations without work responsibilities
  • Nurture friendships
  • Engage in hobbies and other personal interests
  • Limit work hours and caseload
  • Participate in peer support and supervision
  • Engage in personal therapy as needed
  • Journaling
  • Attend to religious or spiritual needs
  • Participate in relaxing activities such as reading, prayer, meditation, listening to music

Applying the Framework and Post-Test

Sally Vignette and Post-Test

Integrated ABC-X Model of Burnout.Integrated ABC-X Model of Burnout.

Sally is overworked at her agency as a result of layoffs (A-stressor). Moreover, her colleagues are also feeling overworked and unappreciated and talk about this often. Sally frequently hears them complain (emotional contagion). Due to her high caseload, she is works long hours and frequently has to miss out on attending her children's sporting events. She is also unable to attend continuing education workshops and conferences like she had planned (B-resources). Although she regularly meets with her supervisor, she is usually not invested in these sessions, as her mind is elsewhere. Compound these difficulties with the fact that she describes herself as a type A personality (C-individual differences/personal susceptibility). As a result of these variables in her life, Sally is beginning to feel emotionally fatigued and drained (emotional exhaustion), and doubts her own abilities as a clinician. Moreover, she has recently noticed that she is losing the ability to be empathic with clients (depersonalization) and is wondering if she has even made a difference in the lives of those she serves (reduced personal accomplishment). Sally notices that she is feeling at the end of her rope and can essentially do two things at this point (cope)

  1. Find ways to take time for herself and/or utilize her supervisor (control coping)
  2. Continue at her pace and without utilizing resources (escape coping)

If she does the former, these strategies utilize her resources and may prevent her from reaching emotional exhaustion, depersonalization, reduced personal accomplishment, and subsequent burnout. If she does the latter, she will likely end up burned out, having to continue to work in an overloaded, unproductive environment, which will continue to compound until Sally becomes ill, ends up quitting, or getting fired for unethical behavior.

Post Test

Clink the link to respond to the following survey:


Audio Companion: Challenges to Therapist Self-Care