Burnout and Self Care in the Helping Professions

By Michael Hughes M.A.

With assistance from Susan Duggan M.Sc. Dev. Psych & B.L.

The reality of burnout and the necessity of self care in the helping profess­ions is becoming more and more recognised as an essential concern for care­givers in developing and maintaining their helping skills. Numerous books, articles, workshops and employee training programmes have been devel­oped to help provide greater support for staff who are under strain from too many demands and not enough resources. One of my favourite titles from these efforts was from an article reviewing the effectiveness of stress management workshops entitled “Two aspirin, lots of fluids and one more workshop …” One of the conclusions was that it is ultimately up to the in­dividual to sort through information currently available and learn to adjust certain behaviours and practise new skills. Unless short and long term goals were put into some kind of formal or informal action plan, the workshops could be just another drain on an already overloaded schedule.

In my trainings I try to make things practical by recommending a research based, comprehensive, lifestyle approach to managing stress, which focuses on self awareness patterns and self care. These skills serve to increase per­sonal resilience and set better limits and boundaries in dealing with others so that a greater balance of effort and relief are established.

Symptoms of Burnout

Symptoms will vary in different people but generally some combination of the following will develop as a signal that something is out of balance. Physical symptoms may include chronic low energy or exhaustion, aches and pains, increased colds, ‘flus and infections, sleep problems. Mental symptoms may include boredom, forgetfulness, poor concentration, fault finding and irritability. People under too much pressure who do not have enough support may have more general feelings of discomfort. They may be disenchanted with life without being able to put a finger on precisely what is wrong. Often they have difficulty in getting along with family, friends and co-workers. They may be disillusioned with their marriages and careers. They can find themselves filled with frustration at having to put increasing amounts of time and energy into maintaining the pace they have set for taking care of others while their own needs go unmet.

Definition

One fairly inclusive definition of burnout is: “Burnout – to deplete oneself, to exhaust one’s physical and mental resources. To wear oneself out by excessively striving to reach some unrealistic expectation imposed by one’s self or by the values of society.” (Dr. H. Freudenberger¹)

Physical patterns of tension and self care

Physically, exhaustion seems to centre in the autonomic nervous system where messages to prepare for effort are sent out to the various systems and organs of the body. Unfortunately, the nervous system has not changed in thousands of years and still over prepares for effort, speeding up some physical systems and turning off others, leading to tension symptoms. More specifically, research has found that in the event of a threat the heart rate is increased, breathing is restricted, adrenalin is increased and the function of the intestine is halted temporarily while energy is mobilized to facilitate other functions, such as muscle tension required for the “fight or flight”, or “stress response”.

Dr. Hans Seyle found that the individual can tend to remain over-mobilized in this alarmed state even when the outside danger has long passed.² The goal of stress management is to learn to adjust this tension and mobilize only the minimal amount of energy appropriate to the task. Since the ever increasing pace and pressure of modern life forces most people to go faster than is healthy, most of us get stuck in what I call the fifth gear syndrome. In effect, stress reduction becomes the practice of learning a better downshifting of the gears. On a long term basis this requires a fundamental re-education of the nervous system usually brought about by practising the relaxation response, and sensory-motor re-education techniques such as the Alexander technique, Felderkrais movement awareness and somatics neuro-­muscular stress reduction exercises. On a short term basis one simple skill is to remember to pause in between activities for at least a few seconds to take a few deep abdominal breaths, shrug your shoulders and talk supportively to yourself. This apparently insignificant momentary pause can actually interrupt and reduce accumulated tensions, stress chemistry and prevent the overloading of physical systems that leads to symptoms.

Research on post traumatic stress³ has shown that fibres of the sympathetic nervous system actually get bigger and fire more quickly when over-stimulated. Again, if not interrupted these patterns of over arousal and strain can lead to nervous signals of physical discomfort such as muscular aches and pains, digestive problems, and even cardiovascular disorders. Research has shown that the demands which most overwork the nervous system are those that are unpredictable, ambiguous and uncontrollable. The most obvious is of the returning war veteran whose system was over-stimulated by unpredictable enemy artillery fire. When he returns home he can be easily restimulated. A bad dream or even the sound of a car back firing can send him into muscle spasms, sweating and panic attacks as if his life were really in danger. In short, it’s as if the thermostat gets stuck and once the sympathetic nervous system is tuned to the over-stimulation frequency, it takes less and less danger to create more and more reactivity. Herbert Benson has called these patterns “disorders of arousal”.

Similarly, but less dramatically, the multiple, unpredictable challenges of helping people, such as empathy on demand, piles of paperwork and numerous meetings are like being on the front lines of the war against pain. The constant strain of being a ‘human doing’ can gradually leave the nervous system habitually tense and in need of repair. Fortunately, research has uncovered another function of the autonomic nervous system which is to rest and repair the body. It takes up to twenty minutes of uninterrupted con­centration for this effect to generalise through the body, effectively reversing the stress response, and returning all systems to neutral. The test techniques for initiating this under-utilised reflex are progressive muscular relaxation, autogenics, breathing exercises, yoga, and concentrative meditations. Once the relaxation response has been re-established, even just a few deep abdom­inal breaths can begin to downshift the nervous system.

The physiological wear and tear on our bodies in the sedentary jobs of the helping professions is rarely considered to be stressful but, in fact, it is. Even just the act of talking increases blood pressure and can overwork the cardio­vascular system and the throat area. Sitting for long periods of time can weaken and tighten the muscles and joints. Commuting to and from work can contribute to physical frustrations. Working more than eight hours per day means even more time is needed to recuperate. One often under­estimated and under-utilised remedy is regular physical exercise which burns up the residue of stress chemicals in the body and increases metabolic efficiency. Regular aerobic exercise has been shown to be as effective as counselling in treating some anxiety and depression.

Perception, empathy and boundaries

Other research in the developing field of psychoneuroimmunology⁴ has shown that the body does not completely know the difference between real and imagined danger. Thus images of problems, danger and pain can often provoke an over-arousal of the body’s defences, spending precious coping energy when it might be conserved and more wisely spent. These pieces of research have important implications for helpers who are often in the presence of other people’s pain and neediness. Helpers can very quickly find themselves straining to offer support for problems over which they have no direct control. And, since they are usually compassionate and caring, this makes them especially vulnerable to the excessive demands that are made on them. They are exposed almost exclusively to the negative sides of the people they work with. The population they are dealing with are often in extreme need, requiring more support than it is humanly possible for one person to provide. They require continual giving and assume an endless supply on the part of the helper. Unless workers remain aware of their limitations as human beings, they will easily be susceptible to some degree of burnout.

Therefore, it is of utmost importance that helpers learn to listen and empathise without taking on too much of the other’s pain. This fine tuned awareness usually takes training and supervision to perfect. The attitude of detachment may seem awkward at first, since most helpers pride themselves in their ability to reach out. It is equally important, however, to develop the ability to lean back, separate awareness patterns and return attention to physical comfort and supportive self talk.

One visualisation exercise that can be helpful in re-establishing bound­aries is as follows: imagine you are surrounded by a thin bubble a few inches from your skin. Then imagine the other person surrounded by their own bubble. Now imagine there is a neutral space in between the two bubbles where there is no direct contact. Now imagine the other person’s bubble expanding and trying to filter into your bubble but you are able to keep some separation between your bubbles with the neutral buffer zone between you in place. Even if you feel impacted or invaded by another’s energy, you can still come back to the original feeling of the separate bubbles with a sense of intermittent disconnectedness from their stress. This exercise works with the sensory motor tract and other areas of the brain, to help interrupt habitual over-exertion of depleting external awareness patterns.

Rescuing, self attention and support groups

We often forget how much energy it takes to listen, empathise and respond supportively. Most people only provide emotional support to a few close friends and family members, but the helping professions are often required to do it for everyone walking through their door with no filtering of incom­patible people. They are routinely exposed to overwhelming demands and are forced constantly to adjust their attention to others’ stressful life events. The Wellness Workbook,⁵ Dr. J.W. Travis discusses how those in the helping professions can get their empathy button stuck in the “on” position and often fall into the pattern of rescuing. A rescuer is a compulsive helper, someone who cannot keep from stepping in to give empathy, support and advice, even when not asked for it. They listen to almost every conversation from the others’ point of view. He says the rescuer will be left unsatisfied because in attending to others, she/he is trying to help, and then feels un­appreciated and depleted. This, he says, is one of the chief causes of burnout in the helping professions.

One of the major drawbacks of focusing on helping others is that it encourages a denial of both personal need and self attention. We often forget that there is an economy of attention in awareness patterns and we have limits to our concentration. Generally, research in perception and cognition suggests we can only pay attention to one thing at a time, and then we switch back and forth between layers of internal and external reality, prioritising certain aspects to construct a sense of meaning. One definition of co-dependence is when we develop an habitual awareness pattern that is more sensitive to other people’s needs and signals of distress than to our own. As we help others review and reorganise their self perceptions we often lose touch with the self attention necessary for monitoring and re­charging our own battery of personal energy.

Certainly other people’s crises tend to overshadow our own needs and we can choose to use our empathy to provide support. But when empathy becomes compulsive it can become a weakness, depleting vital reserves and reducing our capacity for giving further support. A more flexible pattern of awareness that can interrupt compulsive empathy is to keep shifting atten­tion between the client and your own physical sensations. Try to keep subtly adjusting your posture and breath and re-establishing personal comfort as much as possible without abandoning the interaction. Focusing on our own basic functional needs is essential to staying clear and being emotionally present. In that regard, an acronym that is used in many support groups is H.A.L.T. which refers to being too hungry, angry, lonely or tired. These needs, if unattended to, usually distort awareness and can lead to mis-perceptions and then greater tension. The message here is to learn to recog­nise these stages of mind and then halt, and do something to attend to your own basic needs even in the presence of others’ supposedly more important needs.

The metaphor I use in teaching these skills is “muscles of awareness”. The suggestion being that we need to exercise and retrain our awareness muscles to be more flexible and resilient until they become capable of equally responding to internal as well as external needs. Schwartz’s research in self attention is quoted in a fascinating article” by Irish psychologist Michael Delmonte (a respected pioneer in consciousness research) which shows that “self monitoring of all sorts (behavioural, physiological, cognitive) … help(s) engender self-regulation at multiple levels”.

A place to practise these new patterns is in peer support relationships and self care groups where the focus is away from client needs and more towards personal understanding and support. In these environments it is important to discharge the stress of any particularly stressful helping situation. Also, take turns and try to share equal time in admitting any feel­ings of exhaustion, anxiety and irritability as well as accomplishments, satis­factions and self care interests. To some people these practices may be seen as a sign of weakness but the facts disagree. Research into support groups has conclusively shown that feeling understood, accepted and valued strengthens the quality of a person’s life on many levels.

Additional considerations in self care

Research carried out by John Adams⁷, one of the leading experts on Occupa­tional Stress, has indicated that the four most effective strategies of coping with stress were of a “work less hours and work smarter in your lifestyle” type of solution. In order of effectiveness he found that we should try to:

1. Build resistance through healthful lifestyle: deep relaxation, nutritious diet, supportive friendship.
2. Compartmentalise work life and home life.
3. Engage in regular physical exercise.
4. Interrupt strained situations and withdraw physically from them if they become exhaustive.

Probably the best overall book on stress,⁸ The Stress Reduction and Relaxa­tion Workbook, gives step by step directions for practising over a dozen tech­niques proven effective in reducing stress.

In conclusion, I would like to suggest that we have a right and respons­ibility to take care of ourselves, but that this takes some commitment to action. If symptoms persist do not ignore them by saying they are not serious or others are in worse situations. Everyone requires rest, it is not a sign of weakness. It appears that the two main motivators for self care are inspiration or desperation, and unfortunately caregivers often wait until there is a major problem before they change behaviour. If attending to one’s symptoms leads to an awareness of deeper emotional pain then competent psychotherapy is indicated and recommended.

References

(1)   Dr. Herbert J. Freudenberger, Ph.D. Burn out – How to Beat the High Costs of Success, Bantam Books.

(2)   Seyle, H. (1985) Homeostasis and the reactions to stress: A discussion of Walter B. Cannon’s contributions. In The Life and Contributions of Walter Bradford Cannon 1871-1945. New York: State University of New York, Downstate Medical Center.

(3)   George Everly Ph.D. and Herbert Benson M.D. Disorders of Arousal and the Relaxation Response: International journal of PsychosomaticsVol. 36 (1-4): 15-21, 1989.

(4)   Kenneth R. Pelletier and Denise L. Herzing, Psychoneuroimmunology: Toward Mindbody model, Advances, Institute for the Advancement of Health, Vol. 5, No. 1 27-56.

(5)   Travis, John W. (1988) The Wellness Workbook. 2nd Ed. Ten Speed Press, California.

(6)   Michael M. Delmonte, Ph.D. Meditation, The Unconscious and Psychosomatic Disorders, International Journal of Psychosomatics, Vol. 36 (1-4); 45-52, 1989.

(7)   Adams, John D. On Consuming Human Resources: Perspective on the Management of Stress. From Eddy, W.B. and Burke W.W. Behavioural Science and the Manager’s Role, San Diego, CA: University Associates 1980.

(8)   The Stress Reduction and Relaxation Workbook by David, Eshelman & McKay, New Harbinger.

Michael Hughes is a psychologist from California who specialises in teaching stress reduction training programmes for helpers. He will be running Stress Management and Counselling Courses at the Stress Management Institute, Dublin, from November 1996 – April 1997. For further information, contact Susan Duggan, Stress Management Institute 7 Orwell Gardens, Rathgar, Dublin 6. Tel: 01-490 6099.

This article first appeared in Inside Out, Issue 20, Spring 1995 on “Stress and
Burnout”. We reprint it here in response to requests, since Issue 20 is no
longer available, and because the need for Councillors and Psychotherapis
who are working with H.I.V./A.I.D.S. to avoid the dangers of burnout in
their work is noted several times in the current issue.

Editors