Standard Papers
Associations Among Therapist Beliefs,
Personal Resources and Burnout
in Clinical Psychologists
Sally Emery and Tracey D. Wade
School of Psychology, Flinders University, Australia
Sara McLean
School of Psychology, Adelaide University, Australia
There were two aims of the research with 190 Australian clinical psychologists:
(1) to investigate the construct validity of the Therapist Belief Scale (TBS), and
(2) to examine the relative contribution of demographics, workplace variables,
and individual factors to burnout. Construct validity was examined using
exploratory and confirmatory factor analyses and associations between the variables. Multivariate regressions were used to examine the relative contributions to
burnout. The TBS showed three factors related to distress, inflexibility, and control, all of which were significantly associated with lower levels of personal accomplishment. Multivariate analyses showed emotional exhaustion to be associated
being a woman, working for the government, having less personal resources, and
endorsing more therapist beliefs related to control. Higher levels of personal
accomplishment were significantly associated with a lower annual income, not
having a mixed caseload, having more personal resources, and endorsing lower
levels of therapist beliefs related to inflexibility and control.
■ Keywords: therapist beliefs, personal resources, burnout, personal accomplishment
Clinical psychologists are professionals at risk of work stress and burnout. They have
been shown to be affected both personally and professionally by traumatic events
such as patient suicide (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988), and
to have significantly higher levels of emotional exhaustion and depersonalisation
compared with norms provided in the Maslach Burnout Inventory manual (Maslach
& Jackson, 1986) for a heterogeneous group of mental health workers including psychologists, psychotherapists, counsellors, mental hospital staff, and psychiatrists
(Ackerley, Burnell, Holder, & Kurdek, 1988).
Demographic characteristics have been shown to be significantly associated with
burnout in therapists, including younger age (Ackerley et al., 1988; Deutsch, 1984;
Hoeksma, Guy, Brown, & Brady, 1992), and less work experience (Ackerley, et al.,
1988; Kramen-Kahn & Hansen, 1998; Pearlman & Mac Ian, 1995; Ross, Altmaier,
& Russell, 1989; Rodolfa, Kraft, & Reilley, 1988), where years of experience are
often strongly correlated with age. Marital status has generally not been associated
Address for correspondence: Professor Tracey Wade, School of Psychology, Flinders University, GPO Box
2100, Adelaide, SA, 5001, Australia. E-mail: tracey.wade@flinders.edu.au
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Sally Emery, Tracey D. Wade and Sara McLean
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with work stress (Baba, Jamal, & Tourigny, 1998) but married counselling centre
staff experienced more emotional exhaustion than single counsellors (Ross et al.,
1989), perhaps because of greater role conflict between family and work. Consistent
with this suggestion, psychotherapists with young children experienced more
burnout than those without children (Hoeksma, et al., 1993).
A variety of worksite factors have also been found to be associated with work
stress. Private rather than public work settings (Ackerley et al., 1988; Deutsch,
1984) and higher income (Ackerley et al., 1988) have been associated with less
work stress in psychotherapists, although the psychotherapists working privately
were also found to be older, earning more, and spending more hours per week in
direct psychotherapy services than psychotherapists in the public sector (Raquepaw
& Miller, 1989). Working with children was related to greater burnout in trauma
therapists than working solely with adults (McLean, Wade, & Encel, 2003).
Additionally, there has been cross-sectional support for the relationship between
self-care or coping resources and lower work stress, particularly for leisure activities
(Hoeksma, et al., 1993), balance between work and personal life (Cherniss, 1995;
Kramen-Kahn & Hansen, 1998; Shapiro, Dorman, Burkey, & Welker, 1999),
coping skills (Aitken & Schloss, 1994; Sowa, May, & Niles, 1994) and various
aspects of social support (Brown & O’Brien, 1998; Chemtob et al., 1988; Ross et al.,
1989; Savicki, 2002).
Psychotherapy additionally contains unique stressors for the therapist that relate
to the therapist–client relationship and the practice of therapy. In particular, individual factors relating to beliefs about therapy or the therapeutic relationship have
been found to contribute to therapist stress, including the need to work at peak efficiency over all situations with all clients; attitudes of rigidity, inflexibility and dogmatism with respect to the application of therapeutic models and process; the need
to appear knowledgeable; a low tolerance for ambiguity; the need for emotional and
therapeutic control, and an intolerance for client emotionality (Deutsch, 1984;
Forney, Wallace-Schutzman, & Wiggers, 1982; Hellman, Morrison, & Abramowitz,
1987; Rodolfa et al., 1988; Murtagh & Wollersheim, 1997). In one of the few longitudinal studies of work stress, Cherniss (1995) found professionals with unrealistic
expectations such as perfectionism were those least likely to recover from burnout
whereas professionals who made better recoveries were more realistic about their
strengths, weaknesses and work preferences. Beliefs about therapist responsibility for
client welfare have also been rated as stressful (Murtagh & Wollersheim, 1997;
Rodolfa et al., 1988). As part of a ‘self-care plan’ for therapists (Saakvitne &
Pearlman, 1996; Skovholt, 2001), it has been suggested that the active identification and challenging of unhelpful beliefs in therapist training and supervision, with
a view to developing more adaptive, helpful alternative beliefs, may be important in
maintaining therapist mental health. This may be of particular importance for
trainee or inexperienced therapists who appear to be more susceptible to the symptoms of intrusion and avoidance.
Many of the previous investigations of therapists’ beliefs about therapy have either
used unpublished measures (Deutsch, 1984), generic scales of constructs such as
flexibility or rigidity (Hellman et al., 1987), or have investigated beliefs about specific
issues, such as ethical practice (Pope, Tabachnick, & Keith-Spiegel, 1988). Recently,
McLean and colleagues (2003) constructed the Therapist Belief Scale (TBS) consisting of a comprehensive list of beliefs that therapists can have about their work.
The four-step construction procedure has been described in detail previously (McLean
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Associations Among Therapist Beliefs, Personal Resources and Burnout
et al., 2003), where it was found that the more the trauma therapists identified with
unhelpful thoughts, the higher their levels of burnout, where such beliefs made a
greater contribution to the variance of burnout than work-related variables.
There were two aims of the current study. The first was to further investigate the
construct validity of the TBS, which can be used to identify unhelpful therapist
beliefs. This was achieved in two ways: first, we conducted exploratory and confirmatory factor analyses of the TBS with 190 Clinical Psychologists currently
involved in clinical work; second, we examined associations between the TBS,
demographic and workplace variables, coping resources and burnout. It was predicted that a higher endorsement of unhelpful therapy-related beliefs would be associated with higher levels of burnout and a lower level of coping resources. The
second aim was to examine the ability of individual factors to independently contribute to burnout, where we predicted that the individual factors of therapy-related
beliefs and coping resources would account for at least as much of the variance of
burnout as demographics and work factors.
Method
Participants
A list of names and addresses of clinical psychologists with Masters or PhD qualifications and who were currently engaged in clinical practice was obtained from the
South Australian Registration Board. In all, 507 questionnaires were mailed out:
210 in early December 2004 and a further 297 in early February 2005. A total of
200 questionnaires were returned giving a response rate of 39%. Of these, 10 were
returned incomplete with respondents giving reasons of retirement and not working
in clinical practice, leaving 190 valid responses. The response rate was similar to
American studies using mail-outs to members of the American Psychological
Association: 41% (Medeiros & Prochaska, 1988), 35% (Ackerley et al., 1988), 40%
(Hoeksma et al., 1993), and 43% (Gilroy, Carroll, & Murra, 2002).
Characteristics of the sample are shown in Table 1. There were fewer male than
female psychologists, their average age range was 30 to 39 years, they had an average of 5 to 9 years experience working as psychologists and an average annual
income of $40,000 to $49,000. The majority of the sample held a Masters qualification or similar, worked full-time, worked mainly with adult clients, and in public
(government) settings. When asked with whom they lived, a similar proportion
(about one-third) lived with their partner only, as those who had children (either
their own or others’ children and with or without a partner) in their household.
Procedure
A survey package compiled of a participant information sheet, three questionnaires,
and a reply-paid envelope for return of questionnaires was mailed out to each person.
The order of the three questionnaires in the survey package was varied systematically to avoid order effect.
Materials
Demographics and Worksite Factors
Questions on background information covered age, gender, professional training,
years of professional experience, work status (full-time or part-time), client type
(adult, child or both), work setting (government, nongovernment, private), annual
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Sally Emery, Tracey D. Wade and Sara McLean
TABLE 1
Demographic characteristics and percentage of respondents per category
Characteristic
%
Age
Characteristic
%
Sex
20–29 years
17.4
Males
27.9
30–39 years
26.3
Females
71.6
40–49 years
25.3
Work status
50–59 years
21.1
Full-time
62.1
9.5
Part-time
37.4
60+ years
Psych. qualifications
Masters or similar
Work Setting
85.8
Government
45.3
PhD or similar
5.8
Nongovernment
Masters and PhD
7.4
Private
28.4
Govt. and Private
18.4
Annual income
< $20,000
5.3
$20,000–$29,000
9.5
$30,000–$39,000
8.9
No-one
17.4
$40,000–$49,000
8.9
Partner only
37.9
$50,000–$59,000
31.6
Children
37.4
$60,000–$69,000
12.6
Adults (not partner)
$70,000–$79,000
7.9
$80,000 +
Nongovt. & Private
2.1
5.3
Living Arrangement
5.8
Years of Experience
12.7
Client type
< 5 years
31.1
5–9 years
24.7
13.7
Adults
59.5
10–14 years
Children
28.0
15–19 years
10.0
Both
12.5
20+ years
20.5
income and living arrangement (who the respondent lives with). For use in analyses,
living arrangement was recoded to living with children (38%) or not living with
children (62%); work setting was recoded into government setting (45%) or at least
partly private setting (55%); client type was recoded into single client type, adult or
child (72%) or mixed client type, both adult and child (28%).
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Therapist Belief Scale
The Therapist Belief Scale (TBS; McLean et al., 2003) was modified for the current
study. The initial version of the TBS, investigated in 116 therapists, had 56 items,
the majority of which clustered around one primary factor (McLean et al., 2003).
For the present study, an empirical decision was made to include only those items
from the original study that correlated 0.4 and above with this one factor. This
included 36 items, each of which were rated using a 6-point scale ranging from 1
(strongly agree) to 6 (strongly disagree). The wording of four items (items 2, 13, 24,
31) was changed and scoring reversed for these items to avoid response bias. A total
score was obtained by summing the individual item scores, and dividing it by the
total number of items, with higher scores indicating lower levels of endorsement of
the stated beliefs or a healthier belief set around therapy.
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Associations Among Therapist Beliefs, Personal Resources and Burnout
Personal Resources Questionnaire
The Occupational Stress Inventory — Revised (OSI-R, 1998; Osipow, 1998) consists of three scales that measure characteristics of occupational adjustment. In the
current study, only the scale measuring coping resources, the Personal Resources
Questionnaire (PRQ) was used. The PRQ is a 40-item inventory containing four
subscales of 10 items each: Recreation (recreational activities for pleasure and relaxation), Self-Care (personal activities for stress reduction; e.g., healthy diet, exercise), Social Support (support from those around him/her), and Rational/Cognitive
Coping (cognitive skills; e.g., problem solving, prioritising). Each subscale was
scored with a 5-point scale ranging from 1 (Rarely or never true) to 5 (True most of
the time) and items were summed together from all four subscales to form a total
score such that a higher score indicated more resources, and which had an internal
consistency of 0.83. In the current study, item 17 was considered confusing and
changed from ‘I avoid eating or drinking things I know are unhealthy (e.g., coffee,
tea, cigarettes)’ to ‘I don’t smoke cigarettes’. The PRQ is considered a valid and reliable scale with acceptable internal consistency (Osipow, 1998). Construct validity
was found for the PRQ in a survey of 150 staff who worked with people with an
intellectual disability in an Australian government department, where total PRQ
was significantly negatively correlated with anxiety, depression, emotional exhaustion and depersonalisation, and significantly positively correlated with personal
accomplishment (Aitken & Schloss, 1994).
Maslach Burnout Inventory
The Maslach Burnout Inventory — Human Services Survey (MBI-HSS; Maslach,
Jackson, & Leiter, 1996) consists of three subscales that assess three aspects of the
burnout syndrome. The subscales are Emotional Exhaustion (EE; nine items
assessing feelings of being emotionally overextended and exhausted by work),
Depersonalisation (Dp; five items measuring an unfeeling and impersonal response
toward the recipients of care), and Personal Accomplishment (PA; eight items
assessing feelings of competence and successful achievement at work). The frequency
that the respondent experiences each item is rated using a 7-point response ranging
from 0 (Never) to 6 (Every day). Scoring of the subscales involves computing the
total score of the component items for each scale. A high degree of burnout is
reflected in high scores on the EE and Dp subscales and in low scores on the PA subscale. The MBI-HSS has demonstrated good convergent and discriminant validity
(Maslach & Jackson, 1986; Rafferty, Lemkau, Purdy, & Rudisill, 1986) and in the
current study the internal consistency was 0.86 for EE, 0.72 for Dp, and 0.74 for PA.
Statistical Analyses
Investigation of the construct validity of the TBS was investigated in two ways:
using factor analytic approaches and investigating relationships with other variables. First, given that this study was carried out with a larger group of therapists
than the initial study, which was underpowered to detect stable factors (Tabachnick
& Fidell, 2001), another exploratory factor analysis was performed in order to assess
the primary factor profile that existed. Given that there was no a priori expectation
that the factors would be correlated, principal components analysis with a varimax
rotation was carried out, with an identifiable factor requiring an eigenvalue > 1.
Items were only included if they correlated 0.4 and above with at least one of the
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Sally Emery, Tracey D. Wade and Sara McLean
identified factors. Confirmatory factor analysis (CFA) was then used to investigate
structures that best fit the observed data, using correlation matrices for all items generated by PRELIS2, which were then examined in a CFA using Lisrel8 (Jöreskog &
Sörbom, 1996). Evaluation of goodness of fit was carried out using a variety of indicators (as shown in Table 3), including the Tucker-Lewis or Non-Normed Fit Index
(NNFI), a statistic that is relatively free from sample size contamination and imposes
an appropriate penalty function for the inclusion of additional parameters (Ferguson,
Dodds, Ng, & Flannigan, 1994) and the Comparative Fit Index (CFI; Bentler, 1990),
an unbiased counterpart of the fit index originally proposed by Bentler and Bonett
(1980). The CFI evaluates the adequacy of the specified model in relation to the baseline model (the null model), which specifies no relationship among the observed variables, that is, every item is an indicator of a separate latent variable (Feldman, 1993).
As a second way of investigating the construct validity of the TBS, we examined
the association between the TBS scores and the demographic and workplace variables, the three burnout subscales and coping resources. The association with
dichotomous measures was assessed with an independent t test, and the association
with continuous variables was assessed with Pearson correlations.
In order to examine the comparative contribution of the different variables to
the three scales related to burnout, standard multiple regression were examined
where all measures where entered simultaneously.
Results
Descriptives
88
Data were screened for missing values, normality of distributions and outlying
scores. Fewer than 3% of values were missing from all items — an acceptable level
(Tabachnick & Fidell, 2001). Significance tests for skewness and kurtosis plus visual
inspection of graphs revealed two variables were significantly skewed and transformations were applied. A reflection and square root transformation was applied to
the negatively skewed MBI personal accomplishment subscale. The MBI depersonalisation subscale was positively skewed and a log transformation was applied.
Inspection of distributions after transformations revealed scores to be more normally
distributed. The mean scores and standard deviations for personal resources and the
three MBI subscales (EE, Dp, and PA) were 139.2 (15.7), 19.2 (8.6), 4.3 (4.0) and
38.9 (5.1) respectively. The mean score for the total PRQ was slightly higher than
those reported for staff in an Australian government department, who worked with
people with intellectual disabilities, of whom 73% were direct care workers (Aitken
& Schloss, 1994), where the mean score was 129 (SD = 21). This same sample also
reported slightly higher levels of burnout than the sample of psychologists used in
the current study, as did Maslach and Jackson’s 1986 normative sample of doctors
and nurses, with respective means (SD) for emotional exhaustion, depersonalisation
and personal accomplishment of 19.6 (11.0) and 22.2 (9.5), 6.0 (5.4) and 7.1 (5.2),
31.6 (9.2) and 36.5 (7.3). Therefore, the current sample overall may represent a
slightly lower level of experienced burnout than other helping professions.
Factor Analyses
The exploratory factor analysis indicated four factors with eigenvalues > 1, accounting for 39.1% of the variance. Seven items were deleted as they correlated < 0.4
with any of the identified factors, leaving a total of 29 items, as shown in Table 2.
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Associations Among Therapist Beliefs, Personal Resources and Burnout
TABLE 2
Factor Loadings1 (× 100) for Therapist Belief Scale Items With Principal Components
Analysis Using Varimax Rotation
Scale items
Distress Inflexibility Responsibility Control
Factor 1
Factor 2
Factor 3
Factor 4
26. I shouldn’t allow my clients to become
distressed, they really want to feel better.
74
22. I must not allow my client to become
too distressed in therapy.
70
16. Strong emotions will overwhelm and
damage my client because they are
fragile.
66
25. If I have strong reactions to my clients
it means I’m abnormal.
62
19. I must protect my client from reliving
painful events.
61
21. If I allow myself to feel what my client
feels I’ll be damaged.
60
23. If I am affected by my client’s story it will
paralyse me and make me ineffective.
57
12. If I allow my clients to distress me I’m
a failure.
47
3. There is no room for mistakes in therapy.
42
1. I must not make mistakes in therapy
if I do then I’ve failed.
41
42
5. If I just stick to one therapeutic model
it will solve the problem for me.
69
6. Once I have decided on a treatment
model I should stick to it.
68
29. It is unprofessional to take an eclectic
approach to therapy.
67
11. If I deviate from the clinical model
then I’ve failed.
57
17. I must always adhere strictly to a
therapeutic model or I’m unprofessional.
55
32. It is unprofessional to act spontaneously
in therapy.
4. If my clients do not progress it is my
responsibility.
7. I am responsible if therapy is not
successful.
30. It is my role to find the solutions to my
client’s difficulties.
10. The course of therapy should be
predictable.
41
51
61
57
56
55
15. I should be able to achieve results within
a certain time frame.
48
35. I should be emotionally available to my
client at all times.
45
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Sally Emery, Tracey D. Wade and Sara McLean
TABLE 2 (continued)
Factor Loadings1 (× 100) for Therapist Belief Scale Items With Principal Components
Analysis Using Varimax Rotation
Scale items
Distress Inflexibility Responsibility Control
Factor 1
Factor 2
Factor 3
Factor 4
20. If I work hard enough therapy will always
be successful.
41
9. If I don’t understand what happens in
therapy I’m extremely uncomfortable.
68
18. If I don’t have all the information I’m
uncomfortable with therapy.
64
13. I don’t need to fully understand what
happens in therapy in order to help the
client.
64
8. I must fully understand my client or
I won’t feel effective.
49
34. I should treat all clients the same way.
48
14. I must work at peak efficiency at all times.
46
Eigenvalue
4.6
3.3
3.2
3.1
% Variance
12.8
9.0
8.8
8.5
Note: 1 Only items with factor loading > 0.4 are shown.
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Themes of the four factors were: low tolerance of distress, inflexibility with respect
to the application of therapeutic models, beliefs of responsibility for outcome, and
need for control in therapy.
Three confirmatory factor analyses were run examining the goodness of fit of the
data to the three hypothesised structures. The first model tested was the one suggested by the exploratory factor analysis. As can be seen in Table 3, this did not provide a good fit to the data with an overall χ2 of 1100.52 (df = 371), p < .001. In the
second model it was decided to only include items that had factor loadings ≥ 0.60
from the exploratory factor analysis, which resulted in the inclusion of only three
subscales as the beliefs about responsibility subscale was omitted given that it only
contained one item loading ≥ 0.60. These subscales included distress (6 items, α =
0.81, mean = 4.98, SD = 0.69), inflexibility (3 items, α = 0.69, mean = 5.18, SD =
0.84), and control (3 items, α = 0.61, mean = 3.69, SD = 1.04). The overall internal reliability for the total score of these three subscales was 0.78. This provided a
much better fit to the data with a χ2 of 167.38 (df = 51), p < .001. Finally, in order
to ensure that it would not be preferable to simply use the total score, this structure
was tested and had a χ2 of 338.68 (df = 54), p < .001, which was a significantly
worse fit than the previous model (χ2 = 171.30 (df = 3), p < .001). Thus for the
remaining analyses the three subscales of the TBS were used.
Associations With Other Measures
Correlations between therapist beliefs and other continuous measures were small
but in the expected directions (see Table 4). That is, fewer unhelpful therapist
beliefs were associated with being older, having more experience, having more personal resources, and less endorsement of the MBI items, where there was a signifiBehaviour Change
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Associations Among Therapist Beliefs, Personal Resources and Burnout
TABLE 3
Confirmatory Factor Analysis Results for the Therapist Belief Scale
Structure
GFI
AGFI
CFI
NNFI
RMSEA
4 subscales as per
exploratory factor analysis
0.74
0.70
0.71
0.68
0.10
3 subscales where
all items loaded ≥ 0.60
0.87
0.81
0.87
0.83
0.11
Total of the 3 subscales
0.76
0.65
0.68
0.60
0.17
Note: GFI = goodness of fit index where > 0.90 is considered a good fit; AGFI = adjusted goodness of fit
index where > 0.80 is considered a good fit; CFI = comparative fit index where > 0.80 is considered a
moderate fit; NNFI = non-normed fit index where > 0.90 is considered a good fit; RMSEA = root mean
square error of approximation where values between 0.05–0.08 are considered to be a good fit.
cant association between the MBI personal accomplishment subscale and all three
TBS subscales. There were no significant associations between the TBS subscales
and income or MBI depersonalisation.
Associations were also examined between the therapist beliefs and categorical
demographic variables. There were no significant associations with work setting
(government or private) or sex. Therapists who worked full-time reported significantly less endorsement of inflexible therapist beliefs (mean = 5.27, SD = 0.76)
than therapists working part-time (mean = 5.02, SD = 0.95), t(183) = 1.97, p = .05.
Therapists who had a mixed case load (i.e., child and adult) endorsed significantly
more therapist beliefs related to control (mean = 3.45, SD = 1.00) than therapists
who worked either with adults or children (mean = 3.78, SD = 1.05), t(184) = 1.94,
p = .05. Living with children was uniformly related to a higher level of endorsement
of therapist beliefs, including distress, t(181)= –1.93, p = .05, inflexibility, t(181) =
–2.26, p = .03, and control, t(181) = –2.15, p = .03.
Comparative Associations Between the Burnout and Independent Variables
The results of the three multiple regression analyses are shown in Table 5. Very little
of the variance of depersonalisation was accounted for by the current mix of variables,
with only one variable, workplace, reaching significance. Therapists who worked
primarily in government settings experienced greater depersonalisation. Higher levels
TABLE 4
Pearson Product-Moment Correlations Between the Continuous Variables.
Continuous variables
Therapist Beliefs Scale
Distress
Inflexibility
Control
Age
0.19*
0.11
Years of Experience
0.16*
0.03
0.12
Income
0.08
–0.02
–0.03
0.11
–0.19
Personal resources
0.26**
0.16*
MBI emotional exhaustion
–0.10
0.05
–0.19*
MBI Depersonalization
–0.13
–0.08
–0.04
MBI personal accomplishment
–0.21**
–0.22**
–0.17*
Note: MBI = Maslach Burnout Inventory
*p < .05, **p < .01
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Sally Emery, Tracey D. Wade and Sara McLean
TABLE 5
Summary of Multiple Standard Regression Analyses With Burnout as the Outcome
Variable and the Independent Variables Including (1) Demographics, (2) Work Factors
and (3) Individual Factors
Emotional
exhaustion
β (p)
Depersonalisation
β (p)
Personal
accomplishment
β (p)
Demographics
Age
Sex
–0.03 (.76)
0.17 (.04)
–0.16 (.17)
0.03 (.75)
–0.13 (.20)
–0.03 (.74)
Work factors
Years of experience
Full /part time
Annual income
Living with childen
Work setting
Caseload (mixed or not)
0.02 (.82)
–0.13 (.18)
0.16 (.09)
0.04 (.60)
–0.19 (.02)
–0.03 (.72)
–0.08 (.47)
–0.16 (.11)
0.04 (.69)
–0.05 (.57)
–0.16 (.05)
–0.09 (.23)
–0.02 (.80)
–0.07 (.45)
–0.19 (.03)
0.09 (.19)
–0.27 (< .001)
–0.14 (.04)
Individual factors
Personal resources
TBS distress
TBS inflexibility
TBS control
–0.24 (.002)
–0.06 (.50)
0.07 (.37)
–0.18 (.02)
–0.14 (.09)
–0.06 (.50)
–0.05 (.50)
0.002 (.98)
–0.33 (< .001)
0.01 (.92)
–0.18 (.009)
–0.14 (.04)
18%
11%
34%
Adjusted R2
F(p)
F(12) = 3.96 (p < .001) F(5) = 2.67 (p = .003) F(12) = 8.08 (p < .001)
Note: Significant associations are bolded.
of emotional exhaustion were significantly associated with being a woman, working
primarily for the government, having less personal resources, and endorsing more
therapist beliefs related to control. Higher levels of personal accomplishment were
significantly associated with a lower annual income, not having a mixed caseload,
having more personal resources, and endorsing lower levels of therapist beliefs related
to inflexibility and control.
Discussion
92
The current study examined a large sample of South Australian clinical psychologists
with a view to identify the range of variables that are unhelpful to the psychological
health of the therapist, including beliefs about therapy. As such, the first aim was to
further investigate the construct validity of the Therapist Belief Scale (TBS; McLean
et al., 2003). Exploratory factor analysis indicated four coherent factors that reflected
themes of therapy-related beliefs previously found to be unhelpful in psychotherapy
populations. The first factor, low tolerance of distress, related both to distress experienced by the therapist (e.g., ‘If I allow my clients to distress me I’m a failure’) and distress experienced by the client (e.g., ‘I must protect my client from reliving painful
events’). Intolerance for client emotionality has previously been found to be associated with increased levels of therapist distress (Deutsch, 1984; Farber, 1983). The
second factor, inflexibility with respect to the application of therapeutic models,
reflected the belief that only one treatment model or protocol should be used in therapy (e.g., ‘It is unprofessional to take an eclectic approach to therapy’). This may
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Associations Among Therapist Beliefs, Personal Resources and Burnout
reflect the difference between therapy that is driven by protocol rather then principle,
such as the contrast described between ‘standard CBT’ and ‘formulation guided treatment’ (Persons, Roberts, Zalecki, & Brechwald, 2006), where greater flexibility is seen
to be the mark of a more competent CBT therapist (Milne, Claydon, Blackburn,
James, & Sheikh, 2001). In previous research, inflexibility and dogmatism with
respect to the application of therapeutic models and process has been found to be
associated with distress (Hellman, Morrison, & Abramowitz, 1987; Norcross, 1981).
The third factor, which was not supported in a subsequent confirmatory factor
analysis, related to issues of responsibility to outcome, where the therapist takes
responsibility for a successful and timely progress on behalf of the client (e.g., ‘If my
clients do not progress it is my responsibility’). Perfectionistic expectations and ideals
regarding performance and treatment outcome has been previously associated with
therapist distress (Pearlman & Saaktvitne, 1995). The fourth and final factor, the
need for control in therapy, reflected the belief of the therapist that full understanding
was required in therapy for a successful outcome (e.g., ‘I must fully understand what
happens in therapy in order to help the client’). The need for emotional and therapeutic control has been associated with therapist distress (Deutsch, 1984; Hellman et
al., 1987; Rodolfa et al., 1988).
Of the three factors supported by the confirmatory factor analysis, a higher
endorsement of distress beliefs enumerated in the TBS was associated with being a
younger, less experienced therapist, both of which have previously been found to also
be associated with higher levels of burnout (e.g., Hoeksma, et al., 1993), as well
having less personal resources and lower levels of personal accomplishment.
Endorsement of items on the inflexibility scale only had a significant association with
lower levels of personal accomplishment. Endorsement of items on the control subscale of the TBS was associated with younger age, and higher levels of emotional
exhaustion and lower levels of personal accomplishment. In summary, the construct
validity of the TBS looks promising but the low internal reliabilities of two of the
three subscales indicates that further work is required in developing these scales.
However, the TBS may be a useful tool for supervision purposes, where high endorsement of beliefs would indicate a high likelihood of a low sense of personal accomplishment. The scale can be used to highlight unhelpful beliefs where alternative beliefs
can be generated in supervision and tested with behavioural experiments.
The second aim of the current research, which was to examine the ability of individual factors to independently contribute to burnout when taking into account
demographic and work factors, was examined in a multivariate context. While demographic variables were not much implicated as having an association with burnout,
one workplace variable was consistently associated with burnout, namely working primarily for government mental health services. It was of interest to note that for both
the variance of emotional exhaustion and personal accomplishment it was the personal factors that were as strong or stronger contributors as the demographic and
workplace factors. Higher levels of personal resources were a particularly strong contributor, in accordance with previous findings (Aitken & Schloss, 1994; Hoeksma et
al., 1993; Sowa et al., 1994). For both constructs, there were significant associations
with beliefs about control in therapy, and inflexibility beliefs had a significant association with lower levels of personal accomplishment. Overall, these findings give support to a cognitive model of work stress where psychologists’ therapy-related beliefs
should be taken into account along with work factors and personal resources.
However, it should be noted that the majority of the variance of each of the burnout
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Sally Emery, Tracey D. Wade and Sara McLean
scales is not accounted for, with only 11% to 34% of the variance explained for any
one measure. Therefore, greater understanding of work stress will require investigation of a wider range of variables.
The results of the current research must be interpreted in the context of four
important limitations. First, psychologists are more likely to be trained in the cognitive model and hence more aware of, and discriminative of, automatic thoughts than
other mental health workers. Therefore, while results may be generalised to other psychologists or therapists trained in the cognitive model they do not necessarily apply to
mental health workers in general. Second, participation was voluntary and nonresponse may have indicated greater work stress, and although confidentiality was
emphasised there may have been a social desirability bias such that unhelpful therapist beliefs and work stress were underreported and coping resources overreported.
Third, our cross-sectional research can not inform us as to the direction of relationships, namely whether therapist beliefs and lack of coping resources cause work stress
it or whether work stress may lead to unhelpful beliefs and a loss of motivation for
using coping resources. Fourth, as a sample, there was an indication that there was a
slightly lower level of burnout and higher level of coping resources than some other
populations (e.g., Aitken & Schloss, 1994), and therefore a floor effect may exist.
Future research of therapist stress and the contributors to this stress could profitably focus on several issues. First, no convergent validity for the TBS exists, where it
has been compared to other measures of cognitive distortion, such as the
Dysfunctional Belief Scale (Weissman & Beck, 1978), or measures of specific cognitive distortions such as perfectionism, or inflexibility. Such an investigation can
inform us as to whether the TBS provides a valid but unique measure of unhelpful
therapist beliefs. Second, longitudinal research is required in order that issues of
causality can be ascertained. Further to this suggestion, a range of variables should be
examined in conjunction with demographic and workplace variables, therapist beliefs,
and coping resources, so that a greater proportion of variance in therapist stress can be
accounted for. Variables such as social support (both private and in the therapeutic
environment), the quality of the physical therapeutic environment, and types of therapeutic orientation may be useful to study in relation to therapist stress. Third, the
impact of modifying therapist beliefs and coping resources on levels of therapist stress
should be evaluated. If such research indicates decreasing unhelpful beliefs and
increasing use of coping resources can decrease stress, then this would suggest that
more emphasis should be placed in training programs on identifying and challenging
unhelpful beliefs and expectations that therapists may hold with regard to their role
and work. Therapists with less experience may also benefit from an emphasis on these
issues in supervision and support particularly if working in a government setting.
Acknowledgments
94
We thank the South Australian Registration Board for support to send out the questionnaires and the psychologists for taking the time to complete the questionnaires.
A Flinders URB grant supported the collection of data.
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