Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists
Abstract
Objective:
Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation’s largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists.
Methods:
This analysis used data from the VHA’s national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility.
Results:
VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004).
Conclusions:
Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists’ satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.
HIGHLIGHTS
•
The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among 5,341 respondents to the national 2018 Mental Health Provider Survey of the U.S. Department of Veterans Affairs.
•
Therapists had less burnout and more job satisfaction when they perceived being supported in providing evidence-based psychotherapy and measurement-based care, even in analyses adjusted for therapist workload.
•
Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.
Burnout is a syndrome characterized by emotional exhaustion, cynicism or depersonalization, and perceived ineffectiveness at work (1). Among health care workers, mental health providers are among those at highest risk for burnout (2). Burnout is prevalent among therapists, such as psychologists, social workers, and licensed professional mental health counselors (3, 4). In particular, therapists in the Veterans Health Administration (VHA), the nation’s largest integrated health system, exhibit high burnout rates (5–8). In addition to burnout’s negative impact on providers (9–11), this condition leads to reduced clinical efficacy (12–14), increased absenteeism (5, 11, 15), and higher turnover (5, 16). The COVID-19 pandemic has exacerbated these negative outcomes (7, 17). A recent report (18) suggests that clinical social workers and psychologists are some of the specialists most likely to leave their jobs. Thus, therapist burnout poses a substantial and growing problem for health care systems.
The VHA employs 23,000 mental health care providers who serve >1.7 million veterans per year (19) and is the world’s largest employer of social workers (20), the most common providers of psychotherapy. Rates of burnout among VHA psychotherapy providers remain high (5–8). For example, results from a recent analysis (7) indicated that 56% of therapists in VHA posttraumatic stress disorder (PTSD) clinics reported high levels of burnout. Consequently, VHA is highly invested in reducing mental health provider burnout.
The job demands–resources model (21) posits that high job demands (e.g., work pressure and emotional and mental demands) can negatively affect work engagement and performance, but that high job resources (aspects of the job that reduce job demands, aid achievement of work goals, or stimulate personal development) can buffer against this effect. Enhancing job resources improves work engagement and satisfaction (21). On the basis of this conceptual model, we posited that institutional support for evidence-based treatment, including evidence-based psychotherapies (EBPs) and measurement-based care (MBC), represents a job resource that could mitigate burnout and improve job satisfaction among therapists. EBPs are time-limited treatments that have demonstrated effectiveness in ameliorating psychiatric disorders (22). MBC is the regular assessment and tracking of patient-reported outcomes to enhance the efficacy and patient centeredness of care. MBC is associated with improved patient outcomes (23) and complements the delivery of EBPs (24). Provision of dedicated time for EBPs has been associated with greater therapist satisfaction and reduced burnout (25, 26). Stronger EBP implementation predicts reduced burnout (7), and greater adherence to EBPs for PTSD has been positively correlated with a greater sense of professional efficacy (25). Conversely, less knowledge of and confidence in EBPs has been linked to higher burnout in some (26) but not all (25) studies. We therefore hypothesized that greater institutional support for EBPs and MBC would increase work engagement and would decrease job burnout and its symptoms, including emotional exhaustion and depersonalization. Furthermore, because work engagement is associated with a positive work-related state of mind (21), we hypothesized that increased work engagement would be associated with increased job satisfaction.
In recognition of the important roles that EBPs and MBC have in patient outcomes, the VHA has devoted substantial time and resources to disseminating EBPs (27) and MBC (28). VHA also surveys mental health providers annually about perceived quality of care (including EBP delivery and MBC), job satisfaction, and burnout via the Mental Health Provider Survey (MHPS) (29). This survey enables a comprehensive assessment of the association between mental health care practices and therapist burnout. In this study, we used responses from the MHPS to assess associations between burnout and EBP delivery and MBC. On the basis of the existing literature on EBPs and MBC, we hypothesized that higher frequency of EBP delivery and MBC would be associated with lower therapist burnout and greater professional satisfaction.
Methods
We conducted this analysis as part of a larger mixed-methods study that assessed predictors and consequences of mental health provider burnout in the VHA (30). We used burnout and job satisfaction as the outcome variables and two EBP-related domains as predictors; the analyses were adjusted for therapist demographic characteristics as covariates and accounted for correlation within employment facility.
Data Source
We included all respondents to the MHPS (see below), except nurses, psychiatrists, and clinical pharmacists, because these professional groups are unlikely to deliver psychotherapy. We obtained facility-level staffing data from the Mental Health Onboard Clinical Dashboard of the VHA. The U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System Institutional Review Board approved this study.
MHPS
We used individual-level, deidentified data from the 2018 MHPS. The VA Office of Mental Health and Suicide Prevention invites all VHA-licensed and unlicensed independent mental health providers to complete the online MHPS annually to assess mental health providers’ perceptions about access to mental health care, quality of mental health care, and job satisfaction (31). Previous analyses (29) have indicated that the MHPS data are reliable, valid, and consistent with qualitative data. Survey items vary slightly each year. We used data from the 2018 survey because that year’s survey had the greatest number of available items within our domains of interest. We restricted our sample to respondents with complete data for all covariates, for both outcomes, and for at least seven of the eight EBP and MBC items. We also conducted multilevel logistic regression models to predict inclusion status by using demographic variables to identify differences between included and excluded respondents.
Mental Health Onboard Clinical Dashboard
We used staffing ratio data from the Mental Health Onboard Clinical Dashboard. The Office of Mental Health and Suicide Prevention developed a facility-level staffing ratio that estimates the number of full-time equivalent mental health staff per 1,000 veterans treated in outpatient mental health settings (32).
Outcome Measures
Burnout was assessed with the following question: “Overall, based on your definition of burnout, how would you rate your level of burnout?” The response options, on a 5-point scale, were the following: 1, “I enjoy my work. I have no symptoms of burnout”; 2, “Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out”; 3, “I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion”; 4, “The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot”; and 5, “I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.” As in our previous work (8), to aid with interpretability of results, we dichotomized burnout scores by using a cutoff point of 3 and categorized respondents who answered ≥3 as experiencing burnout. This cutoff point showed the greatest agreement with facility-level dichotomous burnout as assessed via responses to two burnout items on the annual employee survey (8).
Therapist Satisfaction
We measured overall therapist satisfaction through a response to the following item: “Considering everything, how satisfied are you with your job?” Response options on a 5-point scale ranged from 1, “very dissatisfied,” to 5, “very satisfied.” We used a cutoff point of ≥4 to indicate job satisfaction.
Independent Variables
We examined two EBP-related domains, EBP and MBC (22, 23), from MHPS questions that were based on the literature (Table 1). The EBP domain contained three individual items (trouble scheduling EBP, sufficient telehealth resources, and shared decision making), and the MBC domain contained five items (difficulty establishing goals, difficulty ending psychotherapy, use patient-reported measures at intake, use patient-reported measures after intake, and useful patient-reported outcome measures). Participants rated all individual items on a Likert scale, with a score of 5 indicating strong agreement. We reverse coded three items; higher scores on any of the other evidence-based practice items indicated greater use of EBP and MBC. We included respondents in analyses if they answered at least seven of the eight items. For those missing an item, we imputed the missing item with the average of the other seven items for that individual. We did not use average domain scores for EBP and MBC because of low internal consistency across items in the EBP and MBC domains. However, the results obtained from the domain scores were similar to the results obtained from the item-level scores reported here. We assessed workload via response to the item “My workload is reasonable given my job”; responses ranged from 1 to 5, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.”
| Variable | Label |
|---|---|
| Evidence-based psychotherapy (EBP) | |
| My schedule is so full that I have trouble scheduling patients for EBP sessionsa | Difficulty scheduling EBPa |
| There are sufficient resources to deliver telehealth (i.e., staff are trained on VA video connect or other telehealth modalities, equipped with video technologies, and supported with appropriate VA bandwidth), ensuring that veterans can access VA EBP from their preferred location | Sufficient telehealth resources |
| Providers discuss options for EBP with veterans as part of treatment planning that engages the veteran in shared decision making | Shared decision making |
| Measurement-based care | |
| Psychotherapy providers at my facility have a difficult time convincing veterans to establish measurable goalsa | Difficulty establishing goalsa |
| Psychotherapy providers at my facility have a difficult time ending psychotherapy when goals are meta | Difficulty ending psychotherapya |
| At intake, how often do you use patient-reported outcome measures for initial assessment among veterans with depression, anxiety, PTSD, or addiction? | Use patient-reported measures at intake |
| After the initial assessment, how often do you use patient-reported outcome measures to assess treatment progress or change among veterans with depression, anxiety, PTSD, or addiction? | Use patient-reported measures after intake |
| Patient-reported outcome measures (e.g., PCL-5, PHQ-9, or BAM)b are useful for evaluating progress and deciding with veterans whether to make changes in treatment | Useful patient-reported outcome measures |
| Workload: my workload is reasonable given my job | Reasonable workload |
a
Reverse coded.
b
BAM, Brief Addiction Monitor; PCL-5, PTSD Checklist for DSM-5; PHQ-9, nine-item Patient Health Questionnaire; VA, U.S. Department of Veterans Affairs.
Demographic Characteristics
Demographic characteristics included VHA tenure (<6 months, between 6 months and 1 year, between 1 and 2 years, between 2 and 5 years, between 5 and 10 years, between 10 and 20 years, and >20 years), VHA training before becoming a VHA employee (yes or no), licensed independent provider (yes or no), type of mental health services provided (outpatient, inpatient, or both), discipline (psychologist, social worker, addiction therapist, peer specialist, licensed professional mental health counselor, licensed marriage and family therapist, or other), membership in the Behavioral Health Interdisciplinary Program (BHIP; an interprofessional team-based approach to mental health care coordination [yes or no]) (33).
Statistical Analyses
We conducted bivariate analyses of dichotomized burnout and job satisfaction versus all independent variables. We then performed multilevel logistic regression to predict burnout and job satisfaction status, with employment facilities as random intercepts. We calculated odds ratios and average marginal effects for each independent variable.
Results
Of the 10,950 respondents to the 2018 MHPS, 7,858 (71.8%) met study criteria of being a therapist. Of these respondents, 2,517 (32.0%) had missing data for at least one covariate or outcome or were missing more than one item of the eight EBP and MBC items. The final sample therefore comprised 5,341 therapists for whom complete data were available on the outcomes, covariates, and seven of the eight main predictors. Using the models predicting inclusion status on the basis of demographic variables, we found that respondents who were excluded were significantly more likely to report their profession as “other” compared with included respondents. Included respondents were significantly less likely to work in inpatient care only and were more likely to work in outpatient care only. Included respondents were also significantly more likely to have BHIP membership.
Among the 5,341 respondents, the mean±SD overall burnout score (on a scale of 1–5) was 2.45±1.01, and the mean overall therapist satisfaction score was 3.67±1.12. Overall, 2,146 (40.2%) respondents reported experiencing burnout, and 3,582 (67.1%) reported experiencing job satisfaction. Our independent variables of interest are shown in Table 1. In bivariate analyses (see the online supplement to this article), higher ratings on each of the EBP and MBC items were significantly associated with lower burnout and greater therapist satisfaction (all p<0.001). In the fully adjusted multilevel logistic regression model predicting burnout (Table 2), less difficulty scheduling EBP (OR=0.83), sufficient telehealth resources (OR=0.84), less difficulty establishing goals (OR=0.82), less difficulty ending psychotherapy (OR=0.89), and reasonable workload (OR=0.44) were all significantly associated with decreased likelihood of burnout. Among the demographic variables used as covariates, tenure of <6 months, compared with tenure of >20 years, was significantly associated with lower burnout (OR=0.41). BHIP membership was also significantly associated with lower burnout (OR=0.86).
| Predictor | Estimate | SE | OR | 95% CI | Average marginal effect | 95% CI | p |
|---|---|---|---|---|---|---|---|
| Difficulty scheduling evidence-based psychotherapy (EBP)a | −.19 | .03 | .83 | .78–.88 | −.03 | −.04, −.02 | <.001 |
| Sufficient telehealth resources | −.18 | .03 | .84 | .78–.89 | −.03 | −.04, −.02 | <.001 |
| Shared decision making | −.01 | .04 | .99 | .91–1.08 | .00 | −.02, .01 | .83 |
| Difficulty establishing goalsa | −.20 | .04 | .82 | .76–.88 | −.03 | −.05, −.02 | <.001 |
| Difficulty ending psychotherapya | −.12 | .04 | .89 | .83–.96 | −.02 | −.03, −.01 | .002 |
| Use patient-reported measures at intake | .04 | .04 | 1.04 | .97–1.12 | .01 | −.01, .02 | .30 |
| Use patient-reported measures after intake | −.05 | .04 | .95 | .88–1.03 | −.01 | −.02, .00 | .20 |
| Useful patient-reported outcome measures | −.06 | .04 | .95 | .88–1.02 | −.01 | −.02, .00 | .14 |
| Reasonable workload score | −.82 | .03 | .44 | .42–.47 | −.14 | −.15, −.13 | <.001 |
| Discipline (reference: all other professions) | | | | | | | |
| Addiction therapist | −.35 | .30 | .71 | .39–1.28 | −.06 | −.15, .04 | .24 |
| Licensed marriage and family therapist | .38 | .47 | 1.47 | .59–3.65 | .07 | −.09, .23 | .42 |
| Licensed professional mental health counselor | −.10 | .26 | .91 | .55–1.49 | −.02 | −.10, .07 | .70 |
| Peer support specialist | −.35 | .26 | .71 | .42–1.18 | −.06 | −.14, .03 | .18 |
| Psychologist | −.05 | .17 | .96 | .68–1.34 | −.01 | −.07, .05 | .80 |
| Social worker | −.03 | .17 | .97 | .70–1.35 | −.01 | −.06, .05 | .85 |
| Previous Veterans Health Administration training (reference: no) | .04 | .08 | 1.04 | .90–1.21 | .01 | −.02, .03 | .57 |
| Licensed independent provider (reference: no) | .10 | .13 | 1.11 | .86–1.44 | .02 | −.03, .06 | .43 |
| Type of mental health services provided (reference: outpatient only) | | | | | | | |
| Both outpatient and inpatient | −.09 | .09 | .92 | .77–1.09 | −.01 | −.04, .01 | .33 |
| Inpatient only | −.12 | .17 | .89 | .64–1.24 | −.02 | −.08, .04 | .49 |
| Job tenure (reference: >20 years) | | | | | | | |
| <6 months | −.90 | .24 | .41 | .25–.65 | −.14 | −.21, −.07 | <.001 |
| 6 months–1 year | −.32 | .21 | .73 | .48–1.10 | −.05 | −.12, .02 | .13 |
| 1–2 years | −.25 | .20 | .78 | .53–1.1 | −.04 | −.10, .02 | .22 |
| 2–5 years | .14 | .16 | 1.15 | .84–1.58 | .02 | −.03, .08 | .38 |
| 5–10 years | .19 | .16 | 1.21 | .89–1.65 | .03 | −.02, .09 | .21 |
| 10–20 years | .18 | .16 | 1.20 | .87–1.64 | .03 | −.02, .08 | .26 |
| Behavioral Health Interdisciplinary Program member (reference: no) | −.15 | .07 | .86 | .75–.99 | −.03 | −.05, .00 | .03 |
| Facility-level staffing ratio | −.01 | .03 | .99 | .94–1.05 | .00 | −.01, .01 | .82 |
a
Reverse coded.
In the fully adjusted multilevel logistic regression model predicting therapist satisfaction (Table 3), less difficulty scheduling EBP (OR=1.09), sufficient telehealth resources (OR=1.21), shared decision making (OR=1.50), less difficulty establishing goals (OR=1.19), less difficulty ending psychotherapy (OR=1.12), useful patient-reported outcome measures (OR=1.20), and reasonable workload (OR=2.16) were all positively and significantly associated with therapist satisfaction. None of the demographic variables were significantly associated with therapist satisfaction.
| Predictor | Estimate | SE | OR | 95% CI | Average marginal effect | 95% CI | p |
|---|---|---|---|---|---|---|---|
| Difficulty scheduling EBPa | .09 | .03 | 1.09 | 1.02–1.16 | .01 | .00, .02 | .008 |
| Sufficient telehealth resources | .19 | .03 | 1.21 | 1.13–1.29 | .03 | .02, .04 | <.001 |
| Shared decision making | .40 | .05 | 1.50 | 1.37–1.63 | .06 | .05, .08 | <.001 |
| Difficulty establishing goalsa | .17 | .04 | 1.19 | 1.10–1.29 | .03 | .01, .04 | <.001 |
| Difficulty ending psychotherapya | .11 | .04 | 1.12 | 1.04–1.21 | .02 | .01, .03 | .004 |
| Use patient-reported measures at intake | .03 | .04 | 1.03 | .96–1.11 | .00 | −.01, .02 | .41 |
| Use patient-reported measures after intake | −.06 | .04 | .94 | .87–1.02 | −.01 | −.02, .00 | .14 |
| Useful patient-reported outcome measures | .18 | .04 | 1.20 | 1.11–1.29 | .03 | .02, .04 | <.001 |
| Reasonable workload score | .77 | .03 | 2.16 | 2.03–2.31 | .12 | .11, .13 | <.001 |
| Discipline (reference: all other professions) | | | | | | | |
| Addiction therapist | −.46 | .29 | .63 | .36–1.11 | −.08 | −.17, .02 | .12 |
| Licensed marriage and family therapist | −.51 | .47 | .60 | .24–1.52 | −.09 | −.24, .07 | .30 |
| Licensed professional mental health counselor | .44 | .27 | 1.56 | .92–2.64 | .07 | −.01, .15 | .09 |
| Peer support specialist | .46 | .28 | 1.58 | .91–2.73 | .07 | −.01, .15 | .09 |
| Psychologist | −.05 | .18 | .96 | .67–1.36 | −.01 | −.06, .05 | .80 |
| Social worker | .22 | .18 | 1.25 | .89–1.76 | .03 | −.02, .09 | .21 |
| Previous Veterans Health Administration training (reference: no) | .08 | .08 | 1.08 | .93–1.26 | .01 | −.01, .04 | .31 |
| Licensed independent provider (reference: no) | −.10 | .14 | .91 | .70–1.19 | −.01 | −.06, .03 | .48 |
| Type of mental health services provided (reference: outpatient only) | | | | | | | |
| Both outpatient and inpatient | .09 | .10 | 1.09 | .90–1.31 | .01 | −.02, .04 | .37 |
| Inpatient only | −.14 | .18 | .87 | .62–1.23 | −.02 | −.08, .03 | .43 |
| Job tenure (reference: >20 years) | | | | | | | |
| <6 months | −.14 | .23 | .87 | .55–1.37 | −.02 | −.09, .05 | .55 |
| 6 months–1 year | −.25 | .21 | .78 | .51–1.18 | −.04 | −.11, .03 | .23 |
| 1–2 years | −.02 | .21 | .98 | .65–1.46 | .00 | −.07, .06 | .92 |
| 2–5 years | .03 | .17 | 1.03 | .74–1.43 | .00 | −.05, .06 | .88 |
| 5–10 years | −.05 | .17 | .95 | .69–1.32 | −.01 | −.06, .04 | .77 |
| 10–20 years | −.15 | .17 | .86 | .62–1.19 | −.02 | −.07, .03 | .36 |
| Behavioral Health Interdisciplinary Program member (reference: no) | .08 | .07 | 1.08 | .93–1.25 | .01 | −.01, .03 | .31 |
| Facility-level staffing ratio | .03 | .03 | 1.03 | .97–1.10 | .01 | .00, .01 | .30 |
a
Reverse coded.
We calculated average marginal effects of each independent variable on dichotomized burnout and therapist satisfaction in each fully adjusted model (Tables 2 and 3 and Figure 1).
FIGURE 1. Associations of satisfaction or burnout with main predictors in the 2018 Mental Health Provider Surveya
aForest plots of average marginal effects with 95% confidence intervals are shown. The analyses were adjusted for facility-level random effects in multilevel logistic regression models. Both analyses were adjusted for demographic characteristics, workload, and facility-level staffing ratio as fixed effects and were adjusted for facilities as random intercepts. An average marginal effect associated with “sufficient telehealth resources” of −0.03 corresponds to a 3-percentage-point reduction in burnout associated with a 1-unit increase in the “sufficient telehealth resources” item.
bReverse coded.
Discussion
In this study, we found that VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for practicing EBPs and MBC. These components of evidence-based treatment contributed independently to therapist satisfaction and burnout, irrespective of whether the analyses were adjusted for workload. These findings suggest that institutional support for evidence-based practices is robustly associated with job satisfaction and reduced burnout among therapists. Expanding support for therapists to provide these services may accrue benefits to therapists, as well as to patients and health care systems.
Our findings are consistent with those of previous reports within and outside the VHA. For example, more time dedicated to EBPs was associated with greater satisfaction among VHA therapists treating patients for PTSD (7). Furthermore, a stronger EBP implementation climate and implementation leadership predicted reduced burnout in this population of clinicians (7). Conversely, less control over when and how to deliver EBPs was associated with greater burnout (7). In another study (34), self-reported use of EBPs by college counseling center staff was negatively correlated with burnout, whereas perceived divergence from research-based practices was positively correlated with burnout. Among trauma therapists in community mental health settings (35), use of EBPs predicted reduced burnout and compassion fatigue and increased satisfaction. Consistent with the job demands–resources model, support of EBPs appears to bolster therapists’ well-being.
Delivery of EBP and MBC may also improve job satisfaction and reduce burnout by improving patient outcomes. For example, we previously reported (8) that VHA mental health providers endorsed experiencing less burnout when they perceived that their work improved veterans’ lives and that their facility offered well-coordinated mental health care. Several studies (34–36) have reported that EBPs enhance self-efficacy. Conversely, therapists with lower self-perceived competence have higher rates of burnout (4). EBPs may also help therapists to feel better equipped to deal with complex client presentations (35) and may provide therapists with a sense of boundaries and structure (37). One study (38) found that perceived overinvolvement in client problems led to greater stress and burnout among therapists. In another investigation (39), role overload had the strongest link to burnout. Finally, EBPs may reduce workload because they are time limited (26, 34).
We also found that therapists’ perceptions of their workload were associated with burnout and job satisfaction. This finding was consistent with previous reports (5, 8, 26, 40) that workload is associated with therapist burnout. These studies have shown that workload continues to contribute to burnout, even in the context of EBP delivery. For example, in a study (26) of community therapists implementing EBPs, greater weekly work hours and larger caseloads were associated with increased emotional exhaustion. Knowledge of EBPs, confidence in delivering EBPs, and positive perception of EBPs were associated with less emotional exhaustion, but these factors did not protect against the detrimental impacts of a heavy workload (26). Notably, EBP implementation activities (including supervision or consultation and MBC) were not associated with emotional exhaustion. Thus, the work of learning and implementing EBPs did not appear to contribute to burnout. Some studies (12) found no clear links between burnout levels and caseload size or severity, suggesting that burnout may be more closely related to perception of workload rather than to objective workload. For example, one study (41) found that therapists who wished that they had smaller caseloads were more burned out than those who were satisfied with their caseloads, irrespective of the actual size of the caseload.
Our study had several limitations. First, the study used cross-sectional data and lacked a control group, for example, of psychotherapists who did not provide EBP or MBC, to compare with psychotherapists who provided EBP and MBC. Systematic differences may exist between facilities that do and do not provide support for therapists to deliver EBP and to use MBC. For instance, better-resourced facilities may provide more support and infrastructure for these activities. However, our results remained statistically significant after the analyses were adjusted for workload and facility-level staffing ratio, suggesting that the positive effects associated with these practices did not solely stem from available facility-level resources. A second limitation was that we could not assess absolute levels of EBP and MBC delivery, but rather, the MHPS measured perceptions of institutional support for these practices. Third, we did not include 32% of the eligible sample because of incomplete data. Excluded individuals differed from included individuals on job type, job setting, and BHIP membership. Notably, we included these factors as covariates in the analyses. Finally, we assessed psychotherapy providers within the VHA system, which may have limited the applicability of the findings to other settings. However, our findings were consistent with previous reports using smaller samples.
Conclusions
In a systemwide survey of VHA therapists, we found that factors facilitating EBP and MBC delivery independently contributed to reduced burnout and greater therapist satisfaction. Future work could assess whether the mechanism of these effects stems from perceived effectiveness of care or whether burnout becomes further reduced when patients experience clinical improvement. Our results suggest that support for the provision of EBPs and MBC may benefit care providers as well as patients and the VA health system. Continued systemwide institutional support for EBP and MBC could promote this positive outcome.
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Information & Authors
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Published In
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Received: 21 February 2023
Revision received: 20 June 2023
Accepted: 4 August 2023
Published online: 26 October 2023
Published in print: March 01, 2024
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Supported by VA Health Services Research and Development Service grants VA-IIR-17-262 and VA-RCS-21-138 (to Dr. Zivin).
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