Chapter 1. The History of Burnout in Society, Medicine, and Psychiatry

Burnout began to receive more attention in the 1970s (Schaufeli et al. 2009; Weber and Jaekel-Reinhard 2000). Around that time, the phenomenon received a comprehensive analysis by the psychologist and psychoanalyst Herbert Freudenberger, Ph.D. (Freudenberger 1980). He seemed to connect the term burn-out (as he spelled it) with the burning out of the substance abusers that he encountered during his mental health care work on the streets. He also felt that those who tried to help such substance abusers were also burning out. In extrapolating from his specific circumstances, he came to feel that a change from an industrial society to a service economy was causing more widespread burnout. Industry was no longer promising lifetime jobs or loyalty to employees. He correctly predicted that as time went on, burnout was also likely to increase in workers in the service economy, including those in healthcare, as healthcare workplaces would begin to be characterized by less loyalty to employees.

Around the late 1970s, a Job Demands-Control Model, labeled job strain, also emerged and became particularly popular in the occupational medical world (Karasek 1979). When high-demand jobs are paired with a low degree of being able to control one’s work, workers seem to be at higher risk for adverse psychological and physical effects.

Around the same time, and apparently independently, the social psychologist Dr. Christina Maslach became interested in a related work phenomenon (Maslach and Leiter 2016). The genesis of Dr. Maslach’s concern emerged with the Stanford Prison Experiment of 1971 (Zimbardo 2008). In this experiment, students who were divided into prison guards and inmates in a mock prison went on to exhibit brutal behavior as “guards” and expressed submissive behavior as “inmates.” The experiment was cut short after 5 days when Dr. Maslach, having just received her Ph.D., witnessed the experiment and told Dr. Philip Zimbardo, who led the research group conducting the experiment, that it was unacceptable to her professionally and personally. After a heated argument, he agreed and ended the experiment.

Forty years later, when interviewed (Ratnesar 2011) about what came to be considered a heroic ethical effort, Dr. Maslach was asked if the prison study experience had something to do with her eminent research on burnout, and she thought it did. She interviewed real prison guards in a real prison and then healthcare workers, including those who worked in hospitals and emergency departments. She and colleagues at Stanford University learned that the workers felt emotionally exhausted, with a loss of idealism when they felt overly controlled (Maslach 1976). They thought that burnout occurred when workers were dealing with a social environment involving certain kinds of stressors and constraints and generally not because they were weak, had poor coping skills, or had mental problems.

To Dr. Maslach’s surprise, her 1976 publication received much attention in the popular press. Even more intrigued, Dr. Maslach developed a method for assessing burnout as a multidimensional construct (Maslach and Jackson 1981). As part of this initial work, burnout was redefined as a response to constant emotional pressure that leads to exhaustion, cynicism, and work stress. It had become apparent at that time that some sort of psychometric tool was needed in order to assess burnout. Using the qualitative research on burnout, Maslach and Jackson (1981) created the Maslach Burnout Inventory (MBI). This scale is composed of three subsections for a total of 22 questions. These sections include nine questions on emotional exhaustion, eight questions on personal accomplishment, and five questions on depersonalization. These questions are answered using a seven-point Likert scale, with higher scores indicating feelings occurring every day or feelings that are very strong.

The MBI has been found to be a relatively reliable, valid tool. One of its major strengths is that it can, and has been, easily adapted to different occupations. It has also been translated into many languages for worldwide use. In addition, in a study investigating the clinical validity of the MBI, researchers tested patients on this scale and then compared the results with a psychiatrist’s assessment of individuals using the criteria of “work-related neurasthenia” as a guideline for burnout. The study concluded that the MBI had strong clinical validity, with results from both assessments being very similar (Schaufeli et al. 2001).

Although the MBI is an excellent tool, it has some limitations. First, it is proprietary and thus has a cost. This has contributed to the use of particular items from the inventory, such as emotional exhaustion, in lieu of the entire MBI. A total score can be derived with the MBI; however, there is no set cutoff score that signifies burnout. In addition, what constitutes burnout in different occupations has been found to vary, in terms of both the overall score and the scores in each subscale of the MBI. Finally, the Likert-style nature of the MBI does not allow researchers to obtain an in-depth understanding of what individuals are feeling (Doulougeri et al. 2016), which is an important concern for psychiatry.

Over the years, the MBI has become the most well-known and most often used proprietary survey tool (Maslach et al. 1996). However, there have been more modifications on how to conceptualize and understand burnout. In 1983, Meir defined burnout as a state that occurs in individuals who expect little reward, in addition to considerable punishment, from their work because of a lack of reinforcement, controllable outcomes, and/or personal competence. Maslach and Jackson (1986) subsequently expanded their prior definition of burnout to include specifically emotional exhaustion, depersonalization instead of cynicism, and a reduced sense of personal accomplishment rather than work stress. Further, in 1988, Pines and Aronson defined burnout as a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations. This became a popular definition for current research because it described burnout as a condition that could occur regardless of the nature of the job. Pines and Aronson used their definition to create a psychometric tool, called the Burnout Measure, to assess burnout in individuals. This scale has 21 questions that assess burnout according to their definition—according to the three components of exhaustion. These questions also are answered using a seven-point Likert scale, with higher scores indicating more significant feelings (Pines and Aronson 1988). This assessment is administered not only in occupational contexts; the assessment is also implemented in nonoccupational areas, for example, the marriage relationship and political conflict (Pines 1994, 1996). Although this tool has also been established as reliable and valid, it should be noted that the Burnout Measure is used in only about 5% of research on burnout, whereas the MBI is used in more than 90% of studies (Schaufeli et al. 2001).

In 1990, the concept of burnout was further developed by Lee and Ashforth (1990), who recognized burnout as a syndrome encompassing the three dimensions of the Maslach and Jackson (1986) model. In 2001, Maslach et al. further expanded upon this by defining burnout as a psychological syndrome relating to chronic interpersonal stressors; and in 2002, Winstanley and Whittington identified burnout as a dynamic process caused by high workload and low coping resources. Two additional revisions were done in 2005. One revision was by Gil-Monte (2005), who believed that there should be a fourth dimension to Maslach’s conception of burnout. Gil-Monte’s definition of burnout included dividing the personal accomplishment dimension into enthusiasm toward the job and feelings of guilt. The other revision, by Kristensen et al. (2005), proposed that Maslach’s definition of burnout was flawed because only fatigue and exhaustion are identified as the core features of burnout. Kristensen et al. argued that depersonalization is a coping strategy for burnout and that reduced personal accomplishment is a consequence of burnout. The definitions of burnout have changed throughout time. However, the most consistently used definition is the one coined by Maslach and Jackson (1981); this is the definition that helped to quantitatively conceptualize burnout through the MBI, the most widely used burnout scale.

There have also been other survey instruments to measure burnout (Louie et al. 2017). In terms of physicians and other healthcare personnel specifically, the Research, Data, and Metrics Working Group of NAM recently concluded that there were several validated instruments available to assess work-related dimensions of well-being. For burnout, they are the MBI-Human Services Survey for Medical Personnel; the Oldenburg Inventory; Physician Work-Life Study’s Single-Item; and the Copenhagen Burnout Inventory. For composite well-being, instruments are the Stanford Professional Fulfillment Index and the Composite Global Well-Being Index.

The term burnout caught on more generally and has continued to be used, even though it is more of a colloquial term than a scientific one. Why hasn’t another term emerged? Perhaps it is because burnout has a metaphoric power in conveying the dying down of worker passion to be like the dying down of a fire’s embers.

Beyond the switching from an industrial to a service society, what other factors seemed to contribute to more burnout? First of all, the “cultural revolution” of the 1960s seemed to weaken the authority of helping paternalistic professionals such as teachers, social workers, police officers, nurses, and physicians. With the development of bioethics around that same time, the importance of the principle of patient autonomy came to rival that of paternalism. Empowered patients began to feel more entitled to ask for what they thought they needed. Even so, as long as the work setting supported the idealism of those professionals adequately, as it did in settings like monasteries, Montessori schools, and religious sectors, burnout was virtually absent (Cherniss and Kranz 1983).

Physicians and dentists generally had only a reported 10% rate of burnout around the year 2000 (Schaufeli et al. 2011). Actually, this 10% rate of burnout was an increase from virtually nothing and was caused by the rise in patient autonomy and the new demands that patients placed on physicians. Thus, some physicians felt blocked and disconnected from their ability to heal when patients demanded something that the physician would not recommend (Tauber 2005).

However, in the mid-1990s, other external forces were emerging along the lines of Freudenberger’s prediction, causing exceptional increases in burnout even among pockets of healthcare professionals that foreshadowed the more general increase of physician burnout as for-profit managed care developed. A study of two staff model health maintenance organizations (HMOs) found that more than half of the physicians reported high emotional exhaustion, a key indicator of burnout (Deckard et al. 1994). Staff models involved physicians being employed and paid a salary. At the same time in community psychiatry, there was a concern that clinical and administrative psychiatrists were losing their authority, while they continued to have ethical and legal responsibility for patient care (Vaccaro and Clark 1996). All these warning signs were apparently ignored in medicine. More generally, the rates of burnout in most physicians, which were relatively low, began rising dramatically at the beginning of the twenty-first century and came to exceed that of other sectors of the economy (Shanafelt et al. 2012).

Although first researched in the United States, by the new millennium the general concern with burnout had spread to countries as diverse as the Philippines and Israel, to Western Europe, and then to Asia, Latin America, Africa, and India (Schaufeli et al. 2009). The interest in the rise of perceived burnout seemed to correspond to the degree of economic development in the countries studied.

Probably because parenting was often not thought of as being work and because of the original focus on the workplace, researching burnout in parents is a more recent phenomenon. It turns out that parental burnout seems to also be on the rise. One study from Belgium reported a high level of burnout of up to 12% for both working women and men who take on more parenting, according to a new parental burnout inventory (Roskam et al. 2017). “So exhausted” was described as the primary symptom. There are more similarities than differences between parental burnout and workplace burnout. Parental obstacles include work obligations and two parents working. Moreover, parental burnout seems even more serious and worrisome to parents than workplace burnout because of how their children are adversely affected. Of course, parental and workplace burnout can coexist and worsen the overall impact of being burned out, which can become crucial for work and home life stress and balance.

The definition of burnout is elusive, despite being studied for almost 50 years. In the early work of Drs. Freudenberger and Maslach, burnout seemed like some sort of syndrome, somewhere between what was considered as normality and a mental disorder. Because it was connected to the workplace and not home life, burnout was regarded as a social problem. One challenge was defining a cutoff for severity in the surveys used. On the MBI, the key subscales measure exhaustion, cynicism, and a sense of being ineffective, with the various kinds of exhaustion receiving the most attention. The question is this: What meaning do the cutoff scores for designating burnout on such scales have (Balon 2017)? Indeed, at least when applied to physicians, there is concern that cutoff scores that result in more than 50% prevalence do not have much clinical or theoretical meaning (Brisson and Bianchi 2017).

A different thread of thought considers burnout to possibly be a medical disorder. Historically, this can be traced back to the emergence of neurasthenia (Schaufeli et al. 2009). Neurasthenia emerged in the early 1800s as a concept to describe a “weakness of the nerves.” Most likely to occur in isolated farm workers or overworked businessmen, the symptoms of neurasthenia included fatigue, anxiety, depressed mood, and headaches. In the United states, this psychopathological diagnosis was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1987 (American Psychiatric Association 1987); it continues to be included in the International Classification of Diseases, 10th Revision (ICD-10) as F48: “Other nonpsychotic mental disorders.” Some physicians equate neurasthenia with severe burnout, as long as the symptoms are work related and the individual is receiving professional treatment. According to this description, it is a culturally accepted diagnosis in some countries, for example, in China (Schwartz 2002).

Although the term burnout as related to job satisfaction is not mentioned in DSM-5 (American Psychiatric Association 2013), it is coded in ICD-10 as Z73, in the category of “problems related to life management difficulty.” This problem is loosely described as “a state of vital exhaustion” (Van Diest and Appels 1991), harkening back to the most emphasized component in the MBI. In Sweden, “exhaustion disorder” was added to their national version of ICD-10 as a medical diagnosis. Criteria included 2 weeks of daily mental exhaustion, difficulty in concentration, decreased ability to cope with stress, irritability, sleep problems, muscle pains, dizziness, or palpitations, along with subjective suffering, impaired work capacity, and not being related to other medical diagnoses. Similarly, the Netherlands has included burnout as a psychiatric illness, characterized by work-related neurasthenia and long-term loss of the occupational role (van der Klink and van Dijk 2003). Thus, in America and Europe, burnout is a popular term for different reasons. In America, it is a nonmedical label that is thus not stigmatized like other psychiatric disorders tend to be. In contrast, in Europe it is a nonstigmatized medical diagnosis that in some welfare states comes with compensation claims and reimbursed treatment programs. Whether burnout is considered a problem or a diagnosis of an illness, it can coexist with other mental disorders. When such coexistence is present, being burned out can inhibit getting help for major psychiatric disorders, or, in turn, having psychiatric disorders can make it harder to recognize coexisting burnout.

Another medical point of view connects burnout with depression. This point of view considers whether burnout leads to clinical depression or, perhaps, whether burnout is a subcategory of depression (Maslach and Leiter 2016). However, the limited neuropsychiatric studies suggest brain changes more similar to those of major trauma in childhood, and physicians have described thousands of everyday microtraumas as the cause of burnout (Michel 2016). That would suggest that burnout could be a subclinical variety of posttraumatic stress disorder (PTSD). As in the description of microtraumas associated with exposure to racism, such everyday microtraumas for physicians would include unrealistic scheduling, system limitations in resources, patient complaints, and administrative criticism or bullying. Cortisol levels that do not return to normal after repeated trauma can lead to a cascade of health problems, including low-grade inflammation and coronary heart disease (Toker et al. 2012). One physician concerned with physician suicide says that physician burnout is actually physician abuse and that the term abuse should be used instead (Wible 2016). That recommendation has not caught on widely, but the physician suicides reported have evoked much concern.

As with soldiers returning from Iraq and Afghanistan, an alternative and overlapping way of describing PTSD is that of a moral injury (Shay 1995). From this perspective, the problem in treating veterans as if they had usual PTSD is that it ignores the moral and ethical dilemmas of committing violence in combat for what may have been questionable reasons.

In healthcare, moral distress has also been discussed in the nursing literature for decades as “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it” (Jameton 1984). Moral distress has more recently been deliberated by veterinarians, especially concerning euthanasia (Moses et al. 2018). For physicians, the moral injury might be the perception that making money for the organization is more important than providing quality care for patients. Similar to burnout, they can sense, or know, that they can potentially provide better care if these system obstacles did not exist, especially if the obstacles are perceived to be unnecessary. If, on the other hand, a physician lowers expectations to accommodate the organization, guilt related to doing so could accumulate over time. Indeed, research is beginning to show a correlation of burnout with mistakes, reduced patient satisfaction, and other quality-of-care problems that could haunt physicians (Shanafelt et al. 2010). Another perspective on moral distress is the finding that enabling physicians to adequately devote 20% or more of their work time to what is most meaningful to and valued by them helps to prevent burnout (Rothenberger 2017).

A psychiatrist, in an excerpt from a poem he wrote, “Numbers Game,” describes his personal guilt and anguish regarding working with for-profit managed care companies (Berlin 2017, available at https://www.psychiatrictimes.com/poetry/numbers-game). Burnout can be an existential crisis in which specific aspects of the work environment make peak, or even adequate, performance impossible (Pines and Aronson 1988).

With the recent emergence of what is termed positive psychology in the United States, burnout can also be considered to be an erosion of work engagement, with engagement being the positive and burnout the negative pole on a continuum of employee well-being (Bakker and Schaufeli 2008). When burnout is viewed this way, burnout prevention turns into the promotion of work engagement.

What burnout is not is compassion fatigue (Carpenter-Song and Torrey 2015). Compassion fatigue comes from a short-term, emotionally draining experience, such as in disaster medicine, or from many years of treating emotionally needy and draining people, including patients (Figley 1995). Burnout, to the contrary, is not a response to long hours on a challenging job, nor does it emerge quickly. In years gone by, medical residents worked much longer hours, as did many physicians in practice. Yet the burnout rate was low, likely because in those work hours, although physicians may have been physically tired at times, the physicians felt that their healing self was being called on and not thwarted. However, there are some data to suggest that physicians with higher degrees of compassion, and possibly empathy, are more vulnerable to burning out (Gleichgerrcht and Decety 2013; Kumar 2016). The reason may be that physicians with high compassion and empathy feel worse when the system thwarts their ability to connect with the patient emotionally. Similarly, feeling that one’s career is a calling, which is so common among physicians, puts one at higher risk for burning out because of being more emotionally taxed and vulnerable to administrative demands and to sacrificing one’s personal life to work demands (Shell 2018).

Recent review studies on the nature and prevalence of burnout clearly indicate that it needs further clarification (Schwenk and Gold 2018). Many physicians suggest that psychiatry, with its experience in classifying mental disorders, is most able to meet this challenge.

The diversity in the definitions of burnout seems to be reflected in the diversity of approaches to prevent, reduce, or treat it (Bahrer-Kohler 2013). Relevant to the presumed causative factors, these approaches to reduce burnout in the general workplace focus on both the individual and the workplace.

It is assumed that there must be some individual variation in vulnerability. This focus is reflected in wellness programs. Such programs may, or may not, be provided in the workplace. Some of the more common recommendations focus on the following:

Similarly, the organization can establish various measures to prevent or reduce burnout, including the following:

In essence, the key is the fit between the worker and the workplace. Therefore, it is a dynamic process of trying to ensure that both the worker’s and the organization’s basic needs are met as best as possible.

There have been some evaluations of the effectiveness of such intervention programs. In a study of 25 primary intervention studies, of which 17 were person directed, 2 were organization directed, and 6 were a combination, 80% of all programs led to some reduction in burnout (Awa et al. 2010). The person-directed interventions modestly reduced burnout in the short term of 6 months or less, whereas the combination interventions had longer-lasting positive effects of 12 months or more. However, in all of these studies, the positive intervention effects diminished over time. There are also natural fluctuations of the degree of burnout because it is a process that reflects various situational and personal factors. The tentative conclusion for the general workplace is that systemwide interventions are best, but intermittent reassessment and refresher programs are necessary for the benefits to continue. However, because burnout in the healthcare workplace is of more recent concern, it is uncertain whether the same conclusion will hold there, although recent research does suggest similar results (Panagioti et al. 2017).

Given the importance of the system, then, the best “treatment” (which would be a cure for burnout) would be to leave the system. Of course, that is not always a practical or desired option. More models and studies are needed before we can develop the kind of expert guidelines we have for DSM disorders.

In medicine, compared with other societal workplaces, concern about reducing burnout was delayed until medicine became more business oriented with the development of for-profit managed care in the 1980s (Moffic 1997). Over time, both patients and physicians became frustrated with the emphasis on cost savings and profit over patient care. Within psychiatry, that frustration was illustrated in the dramatic play Good for Otto by David Rabe. A New York Times review of the play depicted some of those business imperatives in the following excerpt about a patient and therapist (Isherwood 2015):

Although it is beyond the scope of this book focusing on psychiatrists to review burnout in all medical specialties, it may be particularly instructive to focus on a specialty that was one of the first to respond to the repercussions of such business and organizational changes. This specialty is emergency medicine. The endeavors of emergency medicine practitioners can be viewed as an example of a long-term, committed attempt to increase wellness and reduce burnout. The impact of their efforts may have significant meaning for future endeavors in the rest of medicine, including psychiatry.

The premier organization of emergency medicine is the American College of Emergency Physicians (ACEP), which was first established in 1968. In 1989, in response to the concerns of members, ACEP put together a Personal and Professional Well-Being Task Force, with the mission of finding solutions to the barriers and obstacles to having a sense of well-being along with a long, fulfilling career. From this agenda, the group produced a 128-page booklet that has been updated over the years (Manfredi and Huber 2019; available at https://www.acep.org/globalassets/sites/acep/media/wellness/acepwellnessguide.pdf). An Aging Physician Task Force was established around 2005–2006 as an offshoot of this general approach to address concerns related to the experienced emergency physician, including not only the need to continue to provide optimal patient care but also the need to maintain perceived well-being while doing so. Once again, an organizational self-published booklet was issued in 2009 and was reaffirmed in 2015 (American College of Emergency Physicians 2015; available at https://www.acep.org/patient-care/policy-statements/considerations-for-emergency-physicians-in-pre-retirement-years/.

In 1992, ACEP’s Well-Being Committee began offering a “wellness booth” at their scientific assemblies. This consisted mostly of medical testing and the opportunity to take the MBI, with the goal of understanding personal health status and the risk of becoming burned out. In 2004, a Wellness Section was established separately from the Well-Being Committee. This Wellness Section was designed to encourage the development of a community of like-minded practitioners in a psychologically safe environment where discussion related to career journeys could take place, as well as to support the Well-Being Committee’s strategic goals.

Early in these ACEP endeavors, the focus was on what was described as the “self-prong”—personal wellness and resiliency. In other words, the assumption was that “if only I was stronger and better, then everything would be fine.” However, over the ensuing years, this approach seemed to have limited benefits, and some regarded it as blaming the victim. Discussion evolved, and the likelihood that other factors were at play, especially organizational factors in the system in which one works, was recognized.

This perspective was consistent with the burgeoning research studies being conducted simultaneously on the burnout of physicians across specialties. A supportive home life, spirituality, meditation, mindfulness, and embracing positive psychology could all support well-being and resilience, but a disempowering and toxic organizational system could tear all that down (Taylor 2008). A pivotal document was the Rand Report sponsored by the American Medical Association and The Rand Corporation (Friedberg et al. 2013), as it became clearer that the “Triple Aim” of enhancing patient experience, improving population health, and reducing costs was insufficient. Systems need healthy physicians, and the “Quadruple Aim”—with the added fourth aim of improving the work lives of physicians—became an alternative system goal (Bodenheimer and Sinsky 2014). Not only is it now thought that up to 80% of the variance in causing physician burnout is coming from the system, but it is also acknowledged that it is financially sound for organizations to invest in physician well-being (Shanafelt and Noseworthy 2017).

In recognizing the importance of the workplace environment in the process of burning out physicians, the ACEP Well-Being Committee in 2016 internally released Wellness in the Workplace: An Information Paper (available at www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/wellness/wellness-in-the-workplace.pdf), highlighting the importance of redesigning workplaces at the institutional level generally and specifically in the emergency department. Also in 2016, the ACEP Wellness Section sponsored a speaker with expertise as a human factors and systems engineer for their section meeting at the annual ACEP17 Scientific Assembly to help physicians develop the leadership skills to become engaged and empowered partners at the table. Identifying the need to bring onboard a human factors and systems engineer, a unique psychological approach that we often do not see in clinical psychology, was also noted to be relevant in the July 2017 Collaborative Symposia organized by NAM. Indeed, the collaborative work of NAM is viewed as having great potential to comprehensively address the forces primarily causing burnout (Dzau et al. 2018).

Medscape (an online medical information resource) has been conducting surveys of physician burnout for many years using a one-question item. Although there is much criticism over the validity of the survey results, it is the only survey that has been monitoring burnout in physicians year by year. The survey found that the prevalence of burnout among emergency physicians increased over many years and that the rates were among the highest of any specialty. In the 2017 Medscape Lifestyle Report, emergency physicians ranked first among all specialties, at 59%, in having the emergency physicians who participated acknowledge a symptom related to burnout (Peckman 2017). However, in 2018, their ranking dropped to eighth place at 45% (Peckman 2018). If this first-time and unprecedented degree of drop in burnout prevalence in emergency physicians has validity, it suggests that perhaps interventions to reduce burnout in emergency medicine have finally begun to pay off. Those interventions included the following:

Emergency physicians have successfully recognized that to care for the communities that they serve, they need to be supported in focusing on their own well-being. In that light, ACEP’s inaugural wellness conference and retreat took place in February 2019, with the rationale that quality of patient care goes hand in hand with the well-being of physicians (Shanafelt 2009).

The earlier section “Recognizing Burnout in Society” indicated that the study of burnout in general workplaces has spread internationally; burnout has also been studied in psychiatrists in particular. Rates for burnout in psychiatrists seemed to hover around 20% in Milan, Italy (Bressi et al. 2009), and Canada (Kealy et al. 2016). Given that healthcare systems are different in other countries, such studies indicate that there are other significant causes of psychiatrist burnout in addition to factors specific to our systems in the United States.

In contrast to these other countries and the ACEP, organized psychiatry in the United States has been relatively late to join in the concern about wellness and burnout (Moffic 2015). This is despite the fact that psychiatry was an early target of for-profit managed care systems. Scholarly consideration seemed to gain traction in 2016, when a textbook on psychiatric ethics (Roberts 2016) included a chapter on clinician well-being and impairment (Trockel et al. 2016). Recently, an issue of Academic Psychiatry focused on psychiatrist wellness (Gengoux and Roberts 2018). As was the case with emergency medicine, this focus on wellness has been followed by a focus on burnout and on how psychiatrists can contribute our particular expertise and knowledge.

One explanation for this delay is that our rate of burnout seems to be less than that of many other specialties. However, in the annual Medscape surveys, it had climbed above 40% by 2017. Moreover, an early warning sign occurred in community psychiatrists in the mid-1980s, when a small study suggested that about half of community psychiatrists might be burning out (Clark and Vaccaro 1987). This survey followed the dismantling of the federally funded Community Mental Health Act, with a consequent loss of resources, during the administration of President Reagan.

Another explanation is that there are so many everyday practice concerns in our field that we do not “see the forest for the trees.” Ironically, we psychiatrists among all physicians may have been using the defense mechanism of denial even more than other specialists to prevent the painful recognition that we, of all physicians, are burning out. On the other hand, because of our expertise about such defense mechanisms and other psychological processes, we may be able to play a special role in reducing the epidemic increase of burnout in physicians in general (Moffic 2018).

Consider another psychological coping mechanism that has been touted to be an antidote to burnout: resilience. The development of resilience in anyone has been viewed as a positive development—coming back stronger after encountering trauma or other severe stress. Certainly, the inevitable challenges in just becoming a physician lead to increased resilience in most of us. These stressors include the need to master large amounts of relevant knowledge and to cope with patients who die despite our best efforts. Nevertheless, any helpful psychological mechanism can become a problem when used or experienced in excess (Brody et al. 2016; Kumar 2016). In the case of physicians, if the potential of burning out is not kept in mind, more resilience can allow the burning-out physician to plow ahead at work and still claim job satisfaction (Coleman et al. 2015). Such relentless willpower can endanger the physician’s own health, including premature aging of immune cells (DeSteno 2018). To counter that, physicians (if the system in which they work does not) can periodically measure their own burnout, resilience, and job satisfaction with any of the major assessment tools available.

Given that about half of all physicians do not seem to be burning out, it is interesting to consider what the predictors are for well-being. Are the non-burned-out physicians just in a better system, or are they treated better in a disempowering system? In psychiatry, is the still common solo practice—a system of one—a protective factor (Morse et al. 2012)? Or does the development of burnout also have something to do with personal histories and personality? If there is a relationship between burnout and trauma, as suggested earlier (see the section “Definition of Burnout”), those physicians with more of a history of unresolved trauma could be at greater risk (Dunne 2015). For an individual physician, exploring the personal history and meaning of choosing a career in medicine can reveal important psychodynamic issues that might need to be addressed (Pines 2000). For instance, a history of being traumatized by an authority figure would likely increase the psychiatrist’s vulnerability to bullying administrators of disempowering systems.

All medical specialties have their own unique characteristics and stressors. For instance, emergency physicians are routinely first responders to crises and disasters. The unique stressors that may affect a psychiatrist include the following (Maslach and Leiter 2016):

Before psychiatry became more biologically oriented, psychiatrists were expected to have their own psychotherapy when they were in training to better understand themselves and how their personal issues affected patient care. Countertransference—that is, the transferring of one’s personal issues onto the patient—is always looming. Has the disappearance of the expectation of psychiatrists undertaking personal psychotherapy contributed to a lack of collective introspection about a psychological problem like burnout?

Historically, we psychiatrists have also tended not to share publicly much about ourselves. This started with the “blank screen” of classical Freudian psychoanalysts and continues to permeate our concern about personal disclosure. Jung seemed ambivalent about sharing his own self-analytic journal, not sharing it with others during his lifetime (Corbett 2009). This may help explain why we have very few personal disclosures about our own burnout compared with other medical specialists and other mental health care disciplines (Moffic 2017). However, without enough of those narratives, empathy and concern for collegial burnout may be insufficient (Hankir and Zaman 2013).

Given that the rate of burnout continues to increase among most physicians despite many years of trying to reduce it, perhaps psychiatry is the missing therapeutic ingredient (Everett 2017). Time will perhaps tell if we can provide some unique help. In an effort to do so, the APA Board of Trustees Ad Hoc Work Group on Psychiatrist Well-being and Burnout established a portal on the APA website with information on burnout, brief educational videos by members of the work group, and survey tools for burnout and depression (available at www.psychiatry.org/psychiatrists/practice/well-being-and-burnout). Instead of the MBI, because of considerations of cost and concerns about whether the MBI is the best tool to use for psychiatrists, the Oldenburg Burnout Inventory was used (Reis et al. 2015), and a tentative cutoff point of 35 for burnout was established. Those who filled out the survey over the first year had a prevalence rate that was hovering around 74%, with the highest levels among women and early-career psychiatrists.

The work group also developed tools for knowledgeable psychiatrists to be ambassadors to educational systems and organizations to help them in assessing and addressing wellness and burnout. Although tools like the MBI and Oldenburg Burnout Inventory can be used to periodically assess the degree of burnout and the result of interventions in individuals and groups, there are significant pros and cons, as well as ethical concerns, in measuring physician burnout. Administrators could use high scores either to help or to harm given individuals. Therefore, as in patient care (Roberts and Dyer 2004), informed consent might be a minimal requirement for use in those being assessed so that the tools do not add to the sense of disempowerment that contributes to burnout. For psychiatric residents in training, such assessments of burnout could potentially be used during each year of training to monitor their well-being.

Already, the APA has begun to engage other psychiatrists via town hall meetings at the annual APA meeting. Knowing you are not alone in struggling with burnout can be reassuring. Better understanding can be helpful by itself, but this must also lead to better therapeutic tools to be of the most use. The usual therapeutic tools we have for disorders, such as the variety of psychotherapies and medications, are unlikely to be of similar use for burnout if it is different qualitatively from DSM-5 disorders. Perhaps positive psychology and psychiatry approaches would work better as burnout prevention and reduction strategies (Jeste and Palmer 2015). This is already suggested by the popularity of meditation. If burnout results from thousands of microtraumas during the day, then would thousands of moments of joy and awe be an antidote? For instance, pediatric residents seem energized, less cynical, and more confident when attending physicians brought them flowers of gratitude at the end of a rotation, when fellow residents high-fived each other for good bedside manner, and when they embraced each other after some sort of perceived or real failure (Bayer and Capucilli 2018). Gratitude, compassion, and pride seem to provide some relief from the harm of trying to use too much willpower (DeSteno 2018). Humor is a time-tested positive coping mechanism for stress. Some physicians and psychiatrists have incorporated the use of clowning in healing activities for health and mental health problems (Hammerschlag 2011).

Like administrators in all medical specialties, psychiatrist administrators are the conduit for workplace management, at the fulcrum between the financial resources of an organization and the organization’s clinicians; their approach to burnout may well be the key to success in their workplaces (Carpenter-Song and Torrey 2015). The particular psychological attitude and skills of these psychiatrists may make them adept managers, and as psychiatrists, they have unique knowledge, including how to manage regressive group processes that threaten the functioning of the work group (Kernberg 1998). From the perspective of classic psychoanalytic group theory, one helpful strategy for psychiatric administrators is to have a “slight paranoia,” exercising vigilance to protect against envious attacks by members of the organization on the leader. Another is to have an ethical kind of love (Moffic 2016), a sublimated love (Kernberg 1998), for the staff and clinicians. This is the conditional love that will help to empower the clinicians to grow and thrive, along with realistic expectations, akin to what a parent needs to do with children. Of course, although there are no surveys about their specific degree of burning out, psychiatrist administrators must also be aware of their own mental health if they are not empowered and valued by those who are the financial decision makers in their system.

Projecting into the future from our past knowledge, here are some of the ways that the APA can address the challenges of defining and addressing burnout:

The genesis of trying to understand burnout seems to reside more in the social component of psychiatry’s biopsychosocial model (Engel 1980). Historically, the study of clinical practice in prison systems, hospitals, and substance abuse treatment programs led to the scholarly examination of burnout. It is now more evident that the social system generally has a stronger influence on burnout than individual vulnerability. The development of the current epidemic rate of physician burnout can be traced from the loss of authority in some HMO and community psychiatry systems in the mid-1990s; this loss of authority later spread more widely as the dominance of for-profit health systems increased (Tracer 2018). However, uncertainty exists about whether it is possible to simultaneously improve quality, lower costs, and achieve better medical outcomes, let alone add the fourth component of clinician wellness (Burns and Pauly 2018). Ironically, perhaps, the business orientation that helped to cause physician burnout may be an important part of its solution because it is becoming clearer that physician burnout is costly to the organization (West et al. 2018). Even malpractice insurance companies are beginning to support wellness programs, at least in part because they may reduce physician mistakes and the consequent successful lawsuits.

Although psychologists have long been involved in studying and addressing burnout, psychiatrists have not. Perhaps the delayed concern of psychiatrists and psychiatric organizations about burnout will prove to be more beneficial than harmful if we continue to follow the pace and pathways established by the APA Board of Trustees Ad Hoc Work Group on Psychiatrist Well-being and Burnout as it moves forward as a standing APA committee. Ongoing efforts and attention directed to the issue of burnout (as emergency medicine has done) are key because this is not an acute crisis but a chronic one. Our expertise and skills can supplement what has already been learned and done in emergency medicine as well as other medical and mental health care specialties. The NAM is trying to develop a comprehensive model of how to consider burnout in physicians, and psychiatrists can play an important role in this.

To try to summarize a complex challenge, here is a prototype for preventing or reducing burnout, however it is defined, in any workplace: