The Path out of Burnout

The BACP's Therapy Today published this article, and kindly allow me, as author, to duplicate it here. I'd like to thanks Sally Brown whose pushback turned this into a way, way better piece than I first proposed.

I cannot look back on the later stages of my former career in software without feeling physical sensations of guilt and shame. I now know I was experiencing severe burnout, but at the time I felt like an overpaid, underachieving and unemployable fraud. I was totally exhausted, increasingly cynical about the company I had worked for and believed in for 30 years, and utterly incapable of working at the level I was employed at. I ticked all three boxes on the widely used Maslach burnout inventory – emotional exhaustion, negativity and loss of efficacy[1].

But I didn’t know about burnout back then, so this felt personal – this was me, my identity. I remember writing in an intermittently updated journal: ‘Every day I come into work, I feel like I’m clinging to a cliff face by my fingertips, just waiting to fall.’ Eventually recognising that these feelings and sensations were simply part of my burnout was a turning point, and I have seen similar recognition and relief in the counselling room. Now that I’m sitting in the therapist’s chair, I think it’s important to include psychoeducation to explain burnout to clients who may be experiencing it. As well as the Maslach burnout inventory, I may talk about Farber’s three subtypes of burnout: frenetic, the classic escalating stress spiral; worn out, when your best efforts are relentlessly punished; and underchallenged – the least obvious – when life seems lacking in opportunities for growth, validation or achievement[2].

I also find it helpful to be aware of the somatic aspects of burnout. Stress is a biological process, as physical as it is mental, and it’s important to recognise that if you have a client who is so burnt out that they have had to take medical absence from work, this is not simply because they’re ‘not coping’ but are, according to recent research, quite likely to be experiencing the physical effects of excessive noradrenaline, cortisol and serotonin depleting their bodily resources[3]. Again, psychoeducation is key here to challenge any beliefs the client may hold that their physical weakness is merely a manifestation of what they may perceive as their mental weakness.

Social identity

With hindsight I can see how some of the stress dynamics leading to my burnout were rooted in my social identity. As a man I expected to take on financial responsibility for my family, and naturally assumed any difficulties I encountered were entirely my own problem. I had no explanation for the darkening of the sky and the closing in of the walls that I was experiencing, and no model in my personal life for discussing these inner fears and vulnerabilities with friends, colleagues or family.

Each individual’s path into and through burnout is unique, but there are patterns, and social identity can feed into these patterns. Women, for example, although more likely than men to seek support, also face an expectation that they will take on disproportionate levels of emotional labour, looking after the welfare of colleagues as well as their own families. Other identity factors that I have seen influence the burnout path include socio-economic class, sexuality, neurodiversity and minoritised ethnicities. Recent research on intersectionality in public sector burnout shows how the burnout experience varies when the employee subdimensions of gender, ethnicity and age are mapped against the burnout subdimensions of exhaustion, negativity and inefficacy – frustrating for scientists trying to create statistical models but validating for therapists who focus on the diversity of the individual experience[4].

As a runner, I know that the ‘stress + rest = growth’ equation is the key to improvements in performance. When stress becomes chronic, and the rest factor is removed, the effect is the opposite of growth. But we know that what creates stress in people is not universal, and there are also differences between individual capacities to tolerate stress.

Alex’s story

There are some common factors that determine people’s ability to manage everyday or unusual stressful events – one of the most common being the role of relationships. I saw this play out in the case of one client, Alex,* a trader in the City of London, who was married with a daughter. Alex was driven not so much by wealth as by achievement and status, explaining that ‘it’s just that money is the most honest form of recognition’. Recently she had described being at a crossroads where if she didn’t get promoted she would get left behind. Alex found it necessary to take part in after-work drink events, partly as a coping mechanism and partly to reinforce her network. She often came home late and found her wife Bea unsupportive. Alex came to me because Bea had found me online, and asked her to call me.

In our first session Alex told me about the stresses she was dealing with. She had some awareness with regard to her work situation and the growing inadequacy of her coping methods. When talking about her home life, she cast Bea and her daughter Charlie in the role of additional stressors – Bea was grumpy, and Charlie needed to straighten herself out and ‘stop manipulating the system’. I explained how I work and discussed burnout symptoms and patterns with her.

Her sexuality hadn’t met with any outright hostility at work, but she felt that some of her managers had taken a somewhat patronising interest in her and that she’d been invited into their social lives in a rather superficial way, in order to display her to their straight friends. She identified with the first two dimensions of the Maslach burnout inventory – emotional exhaustion and negativity, though less so with loss of efficacy. When I described Farber’s subtypes, she strongly identified with the first, frenetic burnout – ‘That’s me!’ – and I sensed her level of engagement rising. My final intervention was to ask what she would like to focus on for now. She worried about losing her temper with both Bea and Charlie. It became clear to both of us that her primary goal in counselling was to hold her family together.

In our next two sessions she told me more about her situation and her drives. I asked about what drew her to Bea in the first place. I heard of her partner’s beauty and intelligence but also how Alex liked the fact that Bea was dependable and not too demanding. I explained how often I’d heard people tell me about relishing their demanding jobs as long as they’d had stable relationships to go home to, until something went wrong there – sometimes them bringing stress home from work – and then finding they had one too few legs left to stand on. I asked if that felt familiar. There was a long silence – ‘possibly’, she conceded. I asked if they ever had date nights. Alex sighed and said she felt those days had gone.

In a later session she told me that they had left Charlie with her mother and spent a weekend together in Bath. In the next session, she told me about taking Charlie to see a film and how much they both enjoyed the experience. It felt like she was leaning into and enriching both these relationships.

In parallel, we talked about triggers for excessive work drinking – the moment she decides to ‘just go with it’ or, as I suggested, relieve her stress by use of alcoholic disinhibition and inebriated feelings of connection. She began to develop a new career strategy, acting as a mentor for the younger colleagues rather than using them as drinking buddies for stress relief. I got the feeling that her life was getting back on track, and I was a little sad but not surprised when she decided to end counselling after a couple of months.

Culture

Both culture and childhood experience can also shape the process by which stress turns into burnout. When Mia* came to me she was on the path to becoming an NHS consultant, while caring for a widowed mother in poor health, and suffering from anxiety attacks, poor sleep and inability to study for her next set of exams. In the psychoeducation aspect of our work, I introduced another model, Freudenberger’s 12 stages of burnout, which includes compulsion to prove oneself, seeking refuge in overwork, neglect of needs, leading to inner emptiness, depression and full burnout syndrome[5]. This trajectory resonated with her, so part of the work was looking at where this compulsion to prove herself may have come from. I learned that Mia’s immigrant parents valued education and had high expectations of her studying for a profession – an ambition further fuelled by their experience of arriving in poverty to a land of both opportunity and racism. The love in her childhood had all too often been conditional on the achievement of certain goals – when Mia returned from school with a B grade in maths, her mother cancelled her birthday party. From an attachment theory perspective, emotion regulation as an adult can be seen as an internalised reflection of the emotional availability and support of the primary attachment figure in childhood[6]. In Mia’s case, I wondered whether this could have contributed to her difficulties with self-regulation as well as her over-identification with external goals in adult life. She identified with this – part of the reason she worked so hard was to avoid conflict, she said, and she found it difficult to manage criticism or failure.

I was able to help her with the anxiety attacks by the usual means of reframing the symptoms as unpleasant but harmless, and by teaching her breathwork techniques to reduce her physical stress response. Explaining Dan Siegel’s window of tolerance – and identifying the kinds of situations that push her out of that window – was very useful here[7]. I also introduced a brief mindfulness meditation to the sessions so she could become more comfortable with ‘sitting with’ her inner experience. As the sessions progressed, and she began to make more sense of her parents’ behaviour, she also became more robust about drawing boundaries at work. She also started making more space in her life for a previously unmentioned boyfriend, and re-engaging with her professional and exam stresses on her own terms, driven less by reactive responses to external pressures and more by intentional responses to her own rebalanced goals.

Coping mechanisms

It seems that the impact of uncertainty or conflict in relationships becomes more likely to lead to burnout when a client’s usual coping mechanisms are removed, resulting in a persistently lowered tolerance for stress. Don* was a data analyst who enjoyed his work but was in a transition period. When I met him he had left his last job in a Mediterranean country with a high quality of life, which he had hoped would be a good place for him and his fiancée to live together, and was waiting to start his next job back here in the UK. But this wasn’t a normal between-jobs break. I soon discovered that Don was someone who had used exercise as his main stress coping mechanism. Isolated in a foreign hotel, in conflict with a boss who had been his mentor, and with distance and lockdown stretching his relationship to breaking point, he’d gone to the gym and injured his shoulder. But in the next few days, the sprain didn’t heal as it should have, and he found himself so exhausted that he couldn’t go from his room to the lobby without having to sit down and recover.

Along with the physical exhaustion came mental exhaustion he described as ‘brain fog’. He left the job and returned to the UK. By the time we spoke he had found a new job, leaving a month to recuperate before his first day at work. In my initial assessment, I didn’t realise how physical his burnout was – although I was talking to clients daily about the biology of burnout, Don was the most physically burnt out client I had yet encountered. As well as physical and emotional exhaustion, he was experiencing insomnia, gastric issues and had started to have panic attacks. Unsurprisingly, Don was relieved to discover that both his physical and emotional symptoms were very much to be expected from his burnout experience. We were able to evaluate the particular impact of the relationship difficulties in his life, both with his boss who had been his only social connection in that country but had hired him with unrealistic expectations, and with his fiancée who had changed her mind about coming out to join him. The impact of these uncertainties was then magnified by the lack of other relational contact due to physical isolation in his hotel during a strict period of lockdown.

While he felt he was getting better, he was concerned that he might not be fully recovered by the time he started his new job. Over the next two months we discussed what had happened at work and in his private life. We realised that the breakdown of his personal relationship had contributed as much as the work difficulties to his burnout. Making sense of these factors helped him to begin to process his breakdown. He reported that the brain fog was lifting and that he had been able to engage with concluding his relationship and finding a new flat. By the time he returned to work he could focus for most of the day, and this continued to improve. We kept an eye on personal self-care factors such as sleep, wind-down time before bed and a carefully paced return to exercise, and on work self-care factors such as expectation management and time boundaries, and by the time he was a month back at work, he felt recovered and fully engaged.

Life after burnout

Nearly three years on from my burnout job to counselling, and a year into my specialising in working with burnout, I am following my own advice. On the relational front, training as a counsellor made me more aware of my personal relationships, which I think it would be fair to say had suffered from my own emotional exhaustion. I have been able to put more into and get more out of my family and friendships, and have benefited from counselling, and the support of colleagues and supervisors. I cannot help being aware of how much purpose, meaning and learning my clients have generously given me – all of which has made me grateful both to counselling and to family, friends and clients.

Leaving my last job helped me to counteract the exhaustion and procrastination that went with it, while the satisfaction and reward of helping my clients has, in turn, helped me to cope with the stresses of being in private practice. I’m not sure I am so totally recovered that I could contemplate returning to my old line of work, but I am sufficiently recovered that I look forward each morning to the day ahead, and to the personal and professional futures now opening up.

*Client names and identifiable details have been changed

REFERENCES

1. Maslach C. Burnout: the cost of caring. Los Altos: Malor Books; 2015.

2. Farber B. Introduction: understanding and treating burnout in a changing culture.

Journal of Clinical Psychology 2000; 56(5): 589–594.

3. Wolf A. Correspondence (letter to the editor): Gaps in review article. Deutsches Ärzteblatt 2012; 109(18): 340. bit.ly/3FwQWxi

4. Barboza-Wilkes CJ et al. Deconstructing burnout at the intersections of race, gender, and

generation in local government. Journal of Public Administration Research and Theory 2023; 33(1): 186–201.

5. Freudenberger HJ. Counseling and dynamics: treating the end-stage person In: Jones JW (ed). The burnout syndrome. Park Ridge III: London House Press; 1982.

6. Mikulincer M, Shaver PR. Attachment in adulthood: structure, dynamics, and change. New York: Guilford Press; 2010.

7. Siegel DJ. The developing mind. New York: Guilford Press; 1999.

© This article was first published in Therapy Today, the journal of the British Association for Counselling and Psychotherapy (BACP)