It is a most uncommon feat for a disease to be better known by lay people than medical professionals yet over the course of the last decade burnout has gained much more attention in popular press than in the medical field. The DSM-V, also referred to as ‘the Bible of psychiatry, published only 5 years ago and repeatedly criticised for being over-inclusive, does not include a diagnosis of burnout. Paradoxically, initial research in burnout pathology during the 1970’s was conducted with struggling health care professionals. Herbert Freudenberger in his outpatient clinic for addiction in New York City, and later Christina Maslach, researcher at UC Berkeley in California, were the first to describe how health care professionals fell victim to overwhelming symptoms of exhaustion, cynicism and feelings of ineptitude. The burnout syndrome was born.
Nowadays it is no longer a challenge to find data on the prevalence of burnout in different subpopulations of professionals, often stating staggering numbers affected. Burnout prevention and intervention programmes in corporations around the world have blossomed and gurus and consultants have filled a huge gap with employee assistance programmes, stress and time management programmes and so forth. Estimates of the economic cost of burnout to individuals, multinationals and society runs to billions of US dollars each year in developed countries, and yet burnout enjoys still more interest in corporate boardrooms, than in health care settings. In a recent study on burnout prevalence in psychiatry, out of trainees in 22 European countries, 37% met criteria for full blown burnout. A cynical reality, given that these are the doctors of tomorrow responsible for treating patients suffering from burnout.
Unfortunately this hardly seems surprising. Since the dawn of the age of hyper-specialisation in modern medicine and the growing bias towards biological determinants of disease in psychiatry over the last 20 years, the multifaceted pathology of burnout with its unclear pathogenesis seems unwelcome. To complicate things further, even the definition of burnout itself remains somewhat elusive. Maslach defined burnout as “a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform” referring to the 3 symptom dimensions that typify its pathology. Another definition, more poetic than academic, by Maslach, refers to the underlying existential disconnect of burnout patients: “Burnout is the index of the dislocation between what people are and what they have to do. It represents an erosion in value, dignity, spirit, and will – an erosion of the human soul. It is a malady that spreads gradually and continuously over time, putting people into a downward spiral from which it’s hard to recover.”
Research has demonstrated that people with ambitious, conscientious, obsessive and anxious personalities are particularly vulnerable and when engaged in highly stressful jobs (long work hours, high demands and targets, lack of social support and poor communication etc) risk developing burnout, often after many years or even decades of suffering from excessive and chronic stress. In his 1974 article on staff burnout Freudenberger had already suggested 12 phases during which several behaviours and symptoms would develop. He posited that the burnout syndrome lies at the end point of a long downward spiral characterised by physical, mental and social distress.
Since the early research days, it was assumed that exhaustion served as the primary symptom dimension, with lack of personal accomplishment and depersonalisation dimensions as secondary. While the stress-resilience model can clarify how some individuals are more likely to succumb to prolonged occupational stress, it fails to explain the essential two symptom dimensions. Additionally, it does not clarify the reasons for the increasing prevalence of burnout pathology in modern society today. Finally, recent studies have demonstrated that simply increasing stress resistance fails to substantially decrease burnout rates.
But then the question remains: What features of the current world of work are responsible for the burnout pandemic? Certainly, the ascent of modern technology (mobile phones, the internet etc) in a globalised market has accelerated the pace in the modern work environment to unimaginable levels to mimic an ever faster, more competitive race to the top.
Simultaneously, the purpose of work seems to have shifted from a need to generate an income in order to afford to provide for one’s family and lead a life of better comfort, to generate a sense of meaning in life through one’s profession. With the decline of a God to believe in and heaven to aspire to, modern man seems to have substituted a need for a virtuous life with a life driven to self-accomplishment. It is more likely that today we will be greeted by a ‘hello what do you do?’ then a ‘hello who are you?’. Our identity is no longer defined by our culture, our family, our personality, our interests, but instead, by our profession. This process towards professional identification puts enormous emphasis on the value and importance of our jobs.
However, as David Graeber theorises in his latest work ‘Bullshit Jobs’, 40% of modern employees agree to having a ‘bullshit job’, i.e. ‘a form of paid employment that is so completely pointless, unnecessary, or pernicious that even the employee cannot justify its existence even though, as part of the conditions of employment, the employee feels obliged to pretend that this is not the case’. If our identity is defined by our profession, stressing us out through its relentless pace and constant pressure for progress, but seeming intrinsically meaningless, then what do we fight for and, even more importantly, who are we?
Finally, the lure of a neoliberal meritocracy, which presumes that in a competitive market place those with talent and who hard work will ‘make it’, has infused modern man with an insatiable drive towards self-accomplishment. To many this drive no longer serves to generate income or prosperity, but has become the foundation of a meaningful life in itself. Easy to fail, this road leads straight into the burnout cascade. Existence becomes objectified as a project of self-idealisation through one’s profession. As Byung Chul Han puts it: “The achievement subject literally competes with himself and exploits himself until he burns out.”
But even though those suffering from burnout go through enormous pain and suffering that can last for many months, it can also become a period of extraordinary growth for the struggling individual. Burnout patients are confronted with poor choices they made in life, with desires and ineffective habits that have paved the way towards burnout. And so they are forced to really question their true motives and hopes for the future. And ultimately, through existential exploration, reflection and contemplation they may find a way to deeper understanding and fundamental self-acceptance.
Staff burn-out. Journal of Social Issues. 1974;30:159–165.
Maslach, C. Jackson, S. E. & Leiter, M. P. (1996).
MBI: The Maslach Burnout Inventory manual (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.
Maslach, C. & Leiter, M. P. (1997).
The truth about burnout. San Francisco: Jossey Bass.
Jovanovic. et Al
Burnout syndrome among psychiatric trainees in 22 countries
Eur Psychiatry. 2016 Feb;32:34-41. doi: 10.1016/j.eurpsy.2015.10.007. Epub 2016 Jan 21.
The Burnout Society, 2015 Stanford University Press http://www.sup.org/books/title/?id=25725
Jesús Montero-Marín1 et al.
A new definition of burnout syndrome based on Farber's proposal
Journal of Occupational Medicine and Toxicology 2009, 4:31 doi:10.1186/1745-6673-4-31