71465 • Managing and Preventing Burnout

Table of Contents

71465 • Managing and Preventing Burnout

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS

STRESS AND BURNOUT

SUSCEPTIBILITY TO STRESS AND BURNOUT

EFFECTS OF STRESS AND BURNOUT

EXPLORING CASE STUDIES

3. ASSESSMENT OF STRESS AND BURNOUT

4. DEVELOPING A SELF-CARE PLAN

DEEP BREATHING

IMAGERY AND MEDITATION

MAKING TIME

FIVE-MINUTE ACTIVITIES TO MINIMIZE STRESS

PUTTING THE SELF-CARE PLAN INTO ACTION

5. CONSIDERATIONS FOR PROFESSIONALS IN RECOVERY

EXPLORING CASE STUDIES

6. CONCLUSION

7. RESOURCES

Works Cited

71465 • Managing and Preventing Burnout

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

This course will provide strategies to promote enhanced health and well-being. A special component will address the importance of professionals who are in addiction or mental health recovery themselves to maintain stabilization and achieve growth. Relaxation techniques will be reviewed, including deep breathing techniques, imagery exercises, and self-guided meditations that can help professionals to better cope with their work life. Other topics include balancing personal and professional life, recognizing when stress is reaching dangerous levels, coping skills for the workplace, and the importance of healthy lifestyle choices. As part of this course, participants will be exposed to some of the latest research on self-care issues, use personal reflection activities to further explore these concepts, conduct an evaluation of their burnout potential, and develop their own self-care/wellness plan.

71465 • Managing and Preventing Burnout

Education Category. Management

Release Date. 06/01/2025

Expiration Date. 05/31/2028

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3100 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

This course will provide strategies to promote enhanced health and well-being. A special component will address the importance of professionals who are in addiction or mental health recovery themselves to maintain stabilization and achieve growth. Relaxation techniques will be reviewed, including deep breathing techniques, imagery exercises, and self-guided meditations that can help professionals to better cope with their work life. Other topics include balancing personal and professional life, recognizing when stress is reaching dangerous levels, coping skills for the workplace, and the importance of healthy lifestyle choices. As part of this course, participants will be exposed to some of the latest research on self-care issues, use personal reflection activities to further explore these concepts, conduct an evaluation of their burnout potential, and develop their own self-care/wellness plan.

Audience

This course is designed for helping professionals of any kind, including counselors, social workers, therapists, and chemical dependency counselors, who require the tools necessary to address issues of work-life balance.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 4 Non-Clinical continuing education clock hours. NetCE is authorized by IACET to offer 0.4 CEU(s) for this program. NetCE designates this continuing education activity for 4 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 4 continuing education hours for addiction professionals.

Course Objective

Although work stress and burnout are present in every occupation, human service professionals, who spend their work lives attending to the needs of others, are at the highest risk. The purpose of this course is to orient the participants to the ramifications of not taking care of themselves and to promote strategies for enhancing health and well-being as individuals while working as professionals.

Learning Objectives

Upon completion of this course, you should be able to:

1. Distinguish the difference between stress and burnout.

2. Outline the costs of stress and burnout.

3. Identify self-assessment tools for the assessment of stress and burnout.

4. Describe several promising self-care strategies for optimal personal and work functioning.

5. Describe deep breathing, imagery, and meditation and how they may be used to assuage stress and burnout.

6. Discuss the importance of making time for self-care.

7. Identify special considerations for self-care among recovering professionals (both addiction and mental health).

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Self-care can be extremely challenging for helping professionals. Taking care of oneself is critical to survival as professionals and as people, yet it is often neglected in the modern-day human service professions. This course will challenge behavioral health professionals to consider the ramifications of not taking care of themselves while working as professionals. This course uses education to promote strategies for enhancing personal health and well-being, with a special component addressing issues unique to professionals who are in addiction or mental health recovery themselves. Above all, tools for relaxation will be provided, including deep breathing techniques, imagery exercises, and meditations that can enhance coping ability. Other topics will include work/life balancing, recognizing when stress is reaching dangerous levels, coping skills for the workplace, and the importance of healthy lifestyle choices. The latest research on self-care issues will be reviewed, and personal reflection activities will allow for further exploration of these concepts. The course also allows for an opportunity to evaluate burnout potential and develop a self-care/wellness plan.

Because of the print nature of this course, professionals are encouraged to work through at their own pace and to use this course as an opportunity to grow as a clinician. Throughout the course, exercises will be provided. These exercises are designed to further build upon an existing knowledge base. For the exercises that are geared toward relaxation, imagery, and meditation strategies, time may be necessary to complete them as suggested. However, the knowledge gained from these exercises will be a benefit to both everyday life and the work environment.

2. FOUNDATIONS

STRESS AND BURNOUT

Stress and burnout are terms that are often used interchangeably amongst professionals, but their meanings are quite different. Understanding the fundamental meanings of these two concepts and their essential differences is important to develop an overall appreciation of the basics of self-care.

According to the American Psychological Association, stress is the "physiological or psychological response to internal or external stressors. Stress involves changing nearly every system of the body, influencing how people feel and behave" [1]. On the other hand, burnout is defined as [1]:

Physical, emotional, or mental exhaustion accompanied by decreased motivation, lowered performance, and negative attitudes towards oneself and others. It results from performing at a high level until stress and tension, especially from extreme and prolonged physical or mental exertion or an overburdening workload, take their toll.

Interestingly, the word burnout, as described in this passage, was first used by an American psychologist to describe the phenomenon that he observed in human service professionals with unmanageable numbers in their caseloads [3].

It is important to note that burnout applies only to occupational settings. In addition, while burnout is a widely accepted condition, it is not recognized as a standalone medical or mental health diagnosis; it is distinct from, although can be exacerbated by, mental health disorders (e.g., anxiety, depression), general stress, job dissatisfaction, secondary and vicarious trauma, and compassion fatigue [2,8].

It may be helpful to utilize the metaphor of one's work life being a fireplace to understand the fundamental differences between stress and burnout (and how the two can be interrelated). When properly managed, a fireplace continues to stay warm and regulated, serving its purpose to heat the house. Outside stressors, like gusts of air or wind, adding too many logs to the fire, or needlessly poking the fire, can cause it to rage out of control, having the potential to cause serious damage. This is like stress, when work life is overburdened and tasks are not adequately controlled.

Burnout, on the other hand, is the fire going cold. In some cases, the fire dies after it has burned all of its fuel and there is nothing to burn. In other situations, the fire burns out before it is depleted of fuel because of the fire keeper's failure to properly maintain and cultivate the fire. If the fire of professional capacity dies due to lack of care (especially if that capacity had once burned brightly), then all of the other aspects of life (e.g., personal identity outside work) can feel the chill. For those people who are so wrapped up in their professional identities that the other aspects of themselves have disappeared, the loss of the work "fire" can be devastating.

Many who work in the helping professions enter the field with a passion to make a difference. Even when this is the case, if professionals do not take the necessary steps to cultivate their practice and engage in healthy habits, the environmental and pragmatic realities of working in the helping professions can kill the passion that was once a motivator. People who succeed in their profession in the long term are those who have managed to keep the fire regulated over years of working in the difficult conditions that come with the human service professions.

As discussed, stress involves too much: too many pressures that demand too much physically and psychologically. But, stressed individuals have hope that if everything were under control, they would feel better. Burnout, on the other hand, is characterized by exhaustion (feeling depleted, overextended, and fatigued), depersonalization (being detached, withdrawing, having negative/cynical feelings toward one's job), and feelings of inefficacy (reduced feelings of accomplishment or productivity). Professionals experiencing burnout often do not see any hope of positive change in their situations [8]. It is clear that stress is not the same as burnout. The essential difference is that stress involves too much and burnout implies nothing at all and no hope of improvement.

Burnout is typically preceded by the mounting effects of stress that have accumulated and gone unaddressed. For some people, this stress builds over many years. For others, the breaking point can come much more rapidly. However, learning to prevent and to deal with stress now can help prevent burnout, which is a much more difficult condition that should be addressed with professionals. In its publication Addressing Burnout in the Behavioral Health Workforce Through Organizational Strategies, the Substance Abuse and Mental Health Services Administration (SAMHSA) identifies six root causes of burnout at the organizational level [8]:

- Workload: Includes quantity and type of workload. Quantity of workload that contributes to burnout may be characterized by chronic excessive workload, working overtime, excessive hours, infrequent breaks, or time pressures. Burnout may also occur due to the type of work, including work perceived to be in addition to usual work (such as administrative tasks), work in which skills are lacking due to insufficient training or support, feeling vague or uncertain about job responsibilities, and/or underutilization of an employee's skills and abilities. Understaffing also contributes to workload pressures and increases burnout.

- Control: Relates to an employee's capacity to influence their workload and/or work environment, maintain professional autonomy, and have access to resources that support their work. A lack of control in any of these areas may contribute to job disengagement, and eventually burnout. Burnout due to perceived lack of control is especially seen in providers who work in fast-paced, highly demanding environments, such as inpatient settings.

- Reward: Insufficient recognition and/or reward can make employees feel undervalued, leading to withdrawal and burnout. Low salaries and limited career advancement opportunities are common across behavioral health settings, contributing to feelings of underappreciation.

- Community: Relationships within the workplace can be a cause of stress when the employee feels there is insufficient support, trust, or assistance from coworkers or supervisors, or when the general environment of the workplace is negative. Supervisory skills also play a role in stress and burnout; encouraging effective communication, conflict resolution, and team building are essential in building a sense of community within a workgroup.

- Fairness: Decision-making that is not transparent or does not engage employees at all levels can contribute to feelings of unfairness or disrespect. Inequitable procedures can lead to cynicism toward one's job, which can result in burnout.

- Values: A mismatch between an individual's and an organization's values can contribute to burnout as employees may experience less job satisfaction when their work or the organizational culture is not aligned with their personal goals or motivations. Work environments that are diverse and inclusive affect staff's feelings of value and sense of belonging.

Although these organizational-level factors are root contributors to burnout, interpersonal relationships, individual experiences, personality traits, and/or systemic issues in the behavioral healthcare field also play a role. Interpersonal relationships include those with clients, families, and colleagues, and imbalance in any of those areas can create additional stressors. In addition, family-related obligations and maintaining a work/family balance (usually with a strong emphasis on caregiving) can create role strain and place additional stressors on individuals.

Individual-level factors that contribute to burnout include [4,8]:

- Low level of hardiness: Lacking a sense of power over events, disengaging from life activities, resisting change

- External locus of control: Attributing achievements to others or chance versus attributing achievements to oneself (an internal locus of control)

- Poor self-esteem: Lacking confidence in one's abilities

- Avoidant coping style: Responding to stressful situations passively rather than actively

Certain employees may be particularly prone to burnout because of their personality type. For example, employees who are perfectionists, overachievers, or who take on more tasks without sharing responsibilities with other employees may experience burnout. Employees who have a more negative worldview may be more likely to burn out [5].

In addition to organizational and individual level factors, SAMHSA has identified systemic issues in the behavioral health landscape that compound the risk for burnout. These factors include a workforce shortage, an increased need for behavioral health in the general population, budgetary considerations, systemic inequities, and shifts in service delivery and policies (e.g., telehealth, transparency laws) [8].

Each professional should evaluate potential stressors and burnout risk in their own practice. If one feels that he or she is susceptible to burnout, steps may be taken to avoid further progression.

SUSCEPTIBILITY TO STRESS AND BURNOUT

Some professionals are more vulnerable to experiencing stress and burnout than others. Although work stress and burnout are present in every occupation, human service professionals, who spend their work lives attending to the needs of others, are at the highest risk, especially if their work puts them in frequent contact with the dark or tragic side of human experience. This heightened risk is exacerbated if professionals feel underpaid, underappreciated, or criticized for matters beyond their control [5].

NIOSH has identified and described seven risk factors for developing stress or burnout [4]. The first is the nature of the stressor. Central aspects of one's life (e.g., marriage, job) and chronic issues (e.g., a physical handicap, living from paycheck to paycheck) are more likely to cause severe distress than less significant or short-term issues.

The second risk factor is experiencing a crisis. Sudden, intense crisis situations (e.g., being attacked, having an unexpected death in the family) are understandably traumatic. Without immediate intervention and treatment, stress symptoms are common and can lead to long-term debilitation [4].

Multiple stressors or life changes can also contribute to the development of burnout. The more life changes or daily inconveniences one experiences at any one time, the more intense the symptoms of stress [4]. It is important to remember that stress can accumulate. Perception of the stressor influences coping as well. The same stressor can have very different effects on different people. For example, public speaking is a stress for many, but others thrive on it. If a person is able to see some benefit to the situation, the stressor can be easier to deal with.

Knowledge and preparation can counteract the effects of stress. The more one knows about a stressful situation, including how long it will last and what to expect, the better equipped he or she will be to face it. Interestingly, research has indicated that behavioral health professionals who work with clients with severe and persistent mental illness are less likely to feel competent in their abilities and more likely to report stress and burnout symptoms [5]. This is also related to level of stress tolerance. Some people adapt well to changes and obstacles, while others are unable to cope with the slightest frustration or obstacle. Confidence in oneself and perseverance contribute to the ability to gracefully cope with stressful situations.

Lastly, the presence of a support network can prevent the accumulation of stress [4]. A strong network of supportive friends and family members is an enormous buffer against life's stressors. Loneliness and isolation increase the risk of stress and burnout. Organizations can address this factor by fostering a positive work environment and ensuring that professionals have an outlet to discuss problems and potential solutions.

As with many inventories, the greater number of risk factors, the more susceptible an individual is to stress and burnout. Professionals may benefit from evaluating the stress factors in their lives, particularly those that may be improved to mitigate experiences of stress. The exercises presented later in this course will provide tools to decrease these susceptibility factors.

EFFECTS OF STRESS AND BURNOUT

There is a clear connection between workplace stress and physical and emotional issues. Signs of stress and burnout in an individual may include [8,9]:

- Headache

- Sleep disturbance

- Difficulty concentrating

- Fatigue

- Irritability

- Depression

- Anxiety

- Suicidal ideation

- Feelings of hopelessness, futility, despair, boredom, cynicism

- Withdrawal

- Loss of morale

- Isolation

- Negative self-concept

- Social withdrawal

- Inability to regulate emotions

- Gastrointestinal problems

- Excessive weight gain or loss

Evidence indicates that workplace stress plays an important role in several types of chronic health conditions, especially heart disease, musculoskeletal conditions (e.g., back pain, muscle tension), psychological conditions, and substance use disorders [9].

Studies show that stressful working conditions are associated with increased absenteeism, tardiness, workplace injuries, and intent to quit a job. In addition, long-term stress reduces productivity and quality of work, undermines morale, and leads to higher employee turnover, all of which have a negative effect on productivity and profitability. As such, the impact of stress and burnout must be carefully considered by managers and policy makers within a company [8,12]. Additional information and practical suggestions for supervisors to implement positive, cost-effective interventions to assuage the stress experienced by employees are available in the Resources section of this course.

EXPLORING CASE STUDIES

In this section, cases of professionals who are experiencing various levels of stress in their workplaces will be presented. The cases will be revisited throughout the course as solutions to stress and burnout are explored. While reading the cases, think critically about whether the person is experiencing stress or burnout.

Case 1

Ms. Z is a woman, 31 years of age, who just completed her Master's degree in counseling. She is recovering from an alcohol use disorder and has been sober for five years. She is now working her first job as a counselor at a small facility for dual-diagnosis patients. At first, Ms. Z likes her job and feels it is a blessing that she is able to work in an environment that promotes recovery. As a result, her own attendance at 12-step meetings has decreased. About three months into the job, Ms. Z notes that certain aspects of her job are overwhelming. She is finding it difficult to keep up with the rate of discharges and admissions, and she is disheartened that so many patients who she thought would do well are re-admitted to the hospital. Ms. Z has noticed that her heart is beating faster at work, and it is taking her longer to settle down at the end of each day. Nonetheless, she is still optimistic about the prospect of working as a counselor and has been talking actively to her sponsor in Alcoholics Anonymous about how to best cope.

Case 2

Dr. V is a psychiatrist, 50 years of age, who works in an inpatient hospital. Dr. V has been described as unusually kind, compassionate, and empathetic toward patients and colleagues alike. He has a history of dysthymia, for which he received antidepressant therapy. However, Dr. V stopped taking the medication five years ago. Four years ago, Dr. V was offered the position of medical director at a large, reputable psychiatric facility, and he was very excited about procuring this prestigious position. However, Dr. V quickly learned that the job was intense, time-consuming, and stressful. He realized that many of the administrative duties were burdensome, and when dealing with the facility's chief financial officer, he always felt like he was being punished. In the last two years especially, Dr. V has felt that the facility is sacrificing quality of care in order to accommodate more patients. He feels powerless to change much of what he sees wrong in the hospital. Although Dr. V maintains that he enjoys being a psychiatrist, he is wondering if he is right for the position that he once coveted. He recently became concerned when he learned that many of his nurses, who once described him as unusually compassionate, have become afraid to approach him.

Case 3

Ms. P is a social worker, 35 years of age, who has been working for the child protective services agency in her county for seven years. Ms. P's time at work is spent in a crowded cubicle at the office or going out into very dangerous situations in the field. At first, Ms. P enjoyed helping others, but she very quickly found working for the agency, who she perceives as corrupt, to be burdensome. When she entered the field, she was eager to help people but became frustrated that so many of the families she worked with did not seem to want help. At first, she took their rejection of help personally, but over the last several years, she discovered that she just does not care anymore. It is not uncommon for Ms. P to refer to the agency's clients by derogatory names. There are days when she finds herself running to her car at the end of a work day because she is so eager to leave. One day on the way home, Ms. P drives by a local fashion boutique and sees a "Help Wanted" sign. Her thoughts immediately become fixated on applying for a job at the boutique. Although her husband discourages it due to the inevitable pay cut, Ms. P applies for the job and is hired. Happier than ever, Ms. P vows that she will never use her social work degree again.

3. ASSESSMENT OF STRESS AND BURNOUT

Compassion fatigue, or vicarious or secondary trauma, is a term used to describe the emotional exhaustion associated with caregiving. It is relatively common among those in the helping professions, particularly those who care for trauma victims [15,16]. While related to stress and burnout, compassion fatigue is generally brought on by a specific situation [17,18]. Furthermore, those experiencing compassion fatigue retain the capacity for caring, unlike those with burnout. However, an accumulation of stressors can lead to a progression from compassion fatigue to burnout if symptoms are not adequately addressed. On the opposite end of the spectrum, compassion satisfaction refers to the positive feelings associated with helping others through one's work. Assessment of these dimensions can give important insight into one's risk for (or resilience to) burnout.

In order to prevent burnout and improve quality of life, behavioral health professionals are recommended to continually assess their work-life balance. Free self-assessment tools to assess quality of life and burnout risk factors include the Professional Quality of Life measure (https://proqol.org/proqol-health-measure), the Compassion Satisfaction and Fatigue Self-Test for Helpers (http://ncwwi.org/files/Incentives__Work_Conditions/Compassion-Satisfaction-Fatigue-Self-Test.pdf), and the NIOSH Worker Well-Being Questionnaire (https://www.cdc.gov/niosh/twh/php/wellbq) [6,7,14]. The results of these tests can be very helpful when creating a personal self-care plan.

4. DEVELOPING A SELF-CARE PLAN

There are many small steps that can be taken to begin an effective self-care plan. Starting with a few small actions, then adding more as time passes, is a way to ensure that one's unique professional and personal needs are being met.

NIOSH has identified the three essential components of a self-care plan [4,8]:

- Balance between work and family or personal life

- A support network of friends and coworkers

- A relaxed and positive outlook

While this is a good overall framework, many professionals require more specific strategies that will bring the framework to life. The following actions can be taken at work to address feelings of stress and/or burnout; some may be more realistic or applicable than others, depending upon the situation [5]:

- Clarify your job description

- Request a transfer

- Ask for new duties

- Take time off

- Resist perfectionism

- Flip negative thinking and look for the positive

- Take a time out

- Talk about perceived problems or issues

- Recognize sources of support at work

- Find humor in the situation

- Learn how to say "no"

- Avoid people who add stress

- Take control of your environment

- Avoid hot-button topics

- Pare down your to-do list

- Express and share your feelings

- Be willing to compromise

- Be more assertive

- Manage your time better

- Do not try to control the uncontrollable

- Learn to forgive

- Reframe problems

- Look at the big picture

- Do something you enjoy every day

While these suggestions may improve a work situation or environment, it is also vital to address stressors in one's personal life. One way to do this is to adopt a healthy lifestyle. Take time to engage in activities that nourish the body and/or mind in a positive way, such as [5]:

- Exercising regularly

- Eating a healthy diet

- Sleeping seven to eight hours per night

- Spending time in nature

- Talking to a supportive friend

- Writing in a journal

- Taking a long bath

- Playing with a pet

- Getting a massage

- Reading

- Listening to music

Just as it is important to take proactive steps to overall wellness, it is also important to consider what should be avoided in order to fully embrace this lifestyle of self-care. A few habits that should be avoided or eliminated include [5]:

- Smoking

- Self-medicating with alcohol or illicit drugs

- Relying on sleeping pills or tranquilizers to relax

- Overeating or undereating

- Procrastinating

- Withdrawing from friends, family, and activities

In addition to these lists, which provide a good starting point for developing a personalized plan of self-care, there are other steps that may be useful. A spiritual belief system is often a basis for dealing with stress, and clergy or religious leaders can be a valuable resource. Always make time for enjoyable hobbies or activities; even when time is minimal, there may be greater consequences later if all activities that bring joy are abandoned.

Do not be afraid to seek outside help if necessary. Professional counseling may be necessary to deal with the stressors of being a helping professional, and many workplaces offer employee assistance programs that can make a referral. Another major suggestion is to use healthy boundaries at all times, both personally and professionally. Although it is important to have some collegial bonds at work, if possible, avoid workplace drama. Learn who can be trusted and who are positive people to be around.

DEEP BREATHING

Breathing is something most people take for granted. However, not taking the time to really breathe can have serious ramifications on health and wellness. Some have suggested that slow, rhythmic breathing may be the basis of the mechanism synchronizing the brain and the autonomic response. Furthermore, studies have shown a positive relationship between yogic breathing and alleviation of stress, anxiety, and depression [10,11].

The Western medical definition of breath is the air inhaled and exhaled in respiration. Clearly, the absence of breath is typically equated with the absence of life. Those who practice yoga or other Eastern philosophies view breath as even more significant. In Eastern conceptualizations, breath is a life force, the link between the physical and the spiritual. Because most people have not taken the time to notice their breathing patterns, starting breathing exercises can be difficult. Good breathing takes discipline and deliberate practice, but the effects on self-awareness and coping can be considerable.

Like many things in life, breath work takes practice, but developing these breathing techniques is worth the discipline. The more they are practiced, the more effective they will be. It is a simple technique that can focus one's concentration and calm the physiologic responses to stress.

IMAGERY AND MEDITATION

Like breath work, imagery and meditation are also valuable, cost-effective skills that can be used to increase coping and resilience, but they also take practice and discipline. The technical definition of imagery is the "cognitive generation of sensory input from the five senses, individually or collectively, which is recalled from experience or self-generated in a non-experienced form" [1]. Imagery is often conceptualized as putting the imagination to work. Of course, imagery in therapy can be a positive activity used to enhance relaxation or build positive coping skills, or it can be used to promote catharsis of negative, traumatic memories. Imagery, also called visualization, is a powerful tool. Although the concept of meditation often has spiritual connotations, it can simply be viewed as extended thought, reflection, or contemplation for the purpose of restoring a sense of balance. Clearly, imagery and meditation can go hand-in-hand. Whether used together or independently, both can help restore a professional balance.

Imagery can be difficult, particularly for non-visual people. For these individuals, using sounds/music or pleasant scents, such as candles or essential oils, may facilitate relaxation better than visual imagery. A more advanced form of imagery exercises is guided imagery, during which a professional will talk an individual through the visualization.

For additional information regarding imagery and meditation strategies, please see the resources section at the end of this course.

MAKING TIME

Lack of time is possibly the most common excuse professionals give when they are not engaging in self-care activities. In the modern era, when productivity equals survival, it can be too easy to justify not having the time or resources to take care of oneself. However, it is important for individuals who are experiencing symptoms of stress and/or burnout to consider the costs of not making time to reduce stress. Persons who are burned out have difficulty engaging in all aspects of their lives and being there for family and friends. As discussed, stress and burnout also negatively impact productivity. This is particularly important for professionals whose relentless quest to complete tasks is affecting their work and personal lives.

As behavioral health professionals, it is also important to consider the negative influence that stress and burnout can have on clients. If, as psychiatrist Irvin Yalom suggests, the effective therapist should never force discussions of any content area, but should allow sessions to be relationship-driven, attentiveness in all therapeutic sessions is necessary [13]. A heightened sensibility to existential issues influences the nature of the relationship of the therapist and patient and affects every therapy session. Professionals who are stressed or burned out will most likely be less attentive to clients. Failure to engage in effective self-care can be a client care issue.

Making the time to take care of oneself is a personal decision. For some, spending one or two minutes each day practicing breathing or imagery may be a good place to start. When individuals start to see the benefits, they are often inspired to expand their self-care regimen.

FIVE-MINUTE ACTIVITIES TO MINIMIZE STRESS

In addition to having a long-term self-care plan, it is often useful for professionals to have a selection of tools to address stressors when they first appear. These strategies are not meant to be replacements for engaging in a healthy lifestyle, but if they are helpful, they may be incorporated into the self-care plan. These activities can be used to help cope with work, personal, or other stresses.

ACE

The acronym ACE (accept, change, or eliminate) can help one explore available options when feeling stuck or overwhelmed. These options are available in any situation in which one is feeling trapped or stressed. The situation can either be accepted for what it is, changed to the extent possible (which generally means changing something about oneself), or eliminated (e.g., leaving a toxic work environment). After the option has been selected, it should not be revisited until it either continues to add stress or may be addressed more completely.

Make a List

The process of creating a to-do list and marking off completed items is very helpful for some. Even with the proliferation of computer programs that can generate task lists, the act of physically writing may help to expel some of the stress. Maintaining a list can help with organizing and prioritizing critical self-care skills. Crossing items off a list can give a sense of accomplishment and empowerment, which is helpful to get through a stressful day.

The "God" Box

Although this exercise is traditionally referred to as the "God" box, it is not necessary to believe in God to use this technique. If one is not a believer in God, the term can be replaced with another Higher Power or even just referred to as the "away" box.

At home or at your office, earmark a container of some sort. This container can be a shoebox, a small gift box, a bag, or a drawer—any convenient and private container. This container represents "God," "Higher Power," or the energy that will be the recipient of stressors. Whenever a worry of a task is taking up too much mental energy, write it down, fold the paper as many times as possible, and put it in the box. The writing can be detailed or vague. The mantra if the thoughts return could be: "It is in the box…God has it now," or "It is in the box…it is away." It can be interesting to go back and read the slips of paper in the box after weeks or months have passed, as many of the stressors will no longer be an issue.

Slogans and Positive Affirmations

Although slogans, sayings, or clichés can appear trite at first, they can be useful tools and reminders of positive philosophical approaches to life. Some examples of these sayings include:

- Easy does it.

- First things first.

- Acceptance is the answer to all my problems today.

- The pain is not in the letting go, it is in the resistance.

- Have an attitude of gratitude.

- Fake it until you make it.

For some, these slogans are used during deep breathing exercises or meditation to focus thoughts in a positive direction. Others post slogans around their workplace as reminders.

Many behavioral health professionals have used the concept of positive affirmations with clients but have not considered utilizing this tool themselves. Affirmations should be personally significant and empowering; they may be a small or large part of the self-care plan. When an individual is experiencing stress, the affirmations may be repeated until the stress symptoms subside.

Examples of positive affirmations include:

- I can do this.

- I am capable.

- I have dealt with this before; I can do it again.

- I can handle whatever comes.

- Challenges bring opportunities.

PUTTING THE SELF-CARE PLAN INTO ACTION

Formulating a self-care plan is important, but implementing the plan should be the goal. Using the tools provided in this course, behavioral health professionals may be more prepared to cope with the stresses involved in their professions. Evaluating progress and adherence to the plan daily, weekly, or even monthly can help ensure that action is being taken to appropriately deal with stressors and avoid burnout.

It may also be helpful to partner with someone, perhaps a close friend or colleague, who is also creating a self-care plan and check in with each other to see how each is progressing. Having an accountability partner is an effective way to ensure that a self-care plan is successfully executed.

5. CONSIDERATIONS FOR PROFESSIONALS IN RECOVERY

Many behavioral health professionals enter their chosen field because they have had their own experiences with recovery from an addiction, a mental health issue, or a medical issue. The desire to help others often stems from their gratitude that someone once helped them. Recovering professionals may offer important insights into what clients and patients experience. However, it is important to remember that working with recovering patients is not a way to ensure your own personal wellness and recovery. Being healthy as a professional is contingent upon being healthy as a person. Professionals who are in recovery may have to be especially attentive to their own plans of recovery in order to meet the emotional demands of their profession.

Although these questions are specifically regarding addiction recovery, they apply to mental health and medical recovery as well. Too often, functional professionals with long-term conditions that are best treated through medication view the treatment as a sign of weakness. Pride can be a significant roadblock to wellness. Being a mental health professional should not be a barrier to appropriate treatment, either mental or physical. Loss of productivity is just one domain to consider. As discussed, lack of personal wellness can negatively impact the client relationship if it impedes one's ability to be present for the client.

Disclosure of one's recovery from addiction, mental illness, or physical condition is a personal matter that varies greatly depending on the context of the work environment. Many professionals find it beneficial to let their immediate supervisors know about their recoveries in order to ensure an extra level of wellness monitoring. However, behavioral health professionals have every right to be discreet. If this is a consideration, it is advisable to review a company's policy regarding disclosure before accepting a job. In some cases, disclosure of a treatment episode could be required on a licensure application or insurance credentialing forms.

EXPLORING CASE STUDIES

Case 1

Let us return to Ms. Z, a woman who has been working as a counselor and is also recovering from an alcohol use disorder. To deal with her mounting stress, Ms. Z elected to talk to and be honest with her sponsor about her mounting stressors at work and her erroneously held belief that she was getting recovery vicariously through her patients by working with them on their own recovery. As a result, Ms. Z increased her own 12-step meeting attendance to four meetings a week and made a point to attend meetings her patients were not likely to frequent. She and her sponsor also made a plan to check in by phone once a week about the work-recovery issue.

Case 2

Recall also Dr. V, a psychiatrist flirting with burnout. After talking to friends for support, Dr. V decided to visit his own psychiatrist again after five years of being off of medications. Dr. V and his physician mutually decide to initiate a low dose of a selective serotonin reuptake inhibitor antidepressant. He also begins to see a professional counselor again to readdress and redevelop a plan for self-care. For the time being, Dr. V agrees to be monitored by his psychiatrist with appointments every three months.

6. CONCLUSION

The turnover rate is high in the human services professions, due in part to lack of self-care while working in stressful climates. Learning to identify potential stressors and apply basic strategies, such as those discussed in this course, can promote a healthier sense of work-life balance amongst helping professionals. Moreover, personal clinical experience suggests that those clinicians who take the best care of themselves are usually in the best position to take care of their clients. Creating and practicing an effective plan for self-care can improve many aspects of a professional's life and can result in a higher quality of client care.

7. RESOURCES

National Institute for Occupational Safety and Health (NIOSH)

Total Worker Health Toolkit

https://www.cdc.gov/niosh/twh/php/toolkit

NIOSH Worker Well-Being Questionnaire (WellBQ)

https://www.cdc.gov/niosh/twh/php/wellbq

Stress at Work

https://www.cdc.gov/niosh/docs/99-101

Substance Abuse and Mental Health Services Administration (SAMHSA)

Addressing Burnout in the Behavioral Health Workforce Through Organizational Strategies

https://library.samhsa.gov/sites/default/files/pep22-06-02-005.pdf

Occupational Safety and Health Administration (OSHA)

Workplace Stress: Safe Workplace, Good Headspace

https://www.osha.gov/workplace-stress

HelpGuide.org

Burnout: Symptoms, Treatment, and Tips on How to Deal

https://www.helpguide.org/mental-health/stress/burnout-prevention-and-recovery

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