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BioMed Central
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BMC Health Services Research
Open AccessResearch article
Prevalence and associated factors in burnout and psychological
morbidity among substance misuse professionals
Adenekan Oyefeso*1, Carmel Clancy2 and Roger Farmer3
Address: 1Division of Mental Health, Medical School, St
George's, University of London, London SW17 0RE, UK,
2School of Health and Social
Sciences, Middlesex University, F Block, Holborn Union
Building, Archway Campus, Highgate Hill, London N19 3UA,
UK and 3South West
London and St George's Mental Health NHS Trust, Richmond
Royal Hospital, Kew Foot Road, Surrey TW9 2TE, UK
Email: Adenekan Oyefeso* - [email protected]; Carmel Clancy -
[email protected]; Roger Farmer - [email protected]
* Corresponding author
Abstract
Background: Studies of psychological stress among substance
misuse professionals rarely
describe the nature of burnout and psychological morbidity. The
main aim of this study was to
determine the extent, pattern and predictors of psychological
morbidity and burnout among

substance misuse professionals.
Methods: This study was a cross-sectional mail survey of 194
clinical staff of substance misuse
services in the former South Thames region of England, using
the General Health Questionnaire
(GHQ-12) the Maslach Burnout Inventory (MBI) as measures of
psychological morbidity and
burnout, respectively.
Results: Rates of psychological morbidity (82%: 95% CI = 76–
87) and burnout (high emotional
exhaustion – 33% [27–40]; high depersonalisation – 17% [12–
23]; and diminished personal
accomplishment – 36% [29–43]) were relatively high in the
study sample. High levels of alienation
and tension (job stressors) predicted emotional exhaustion and
depersonalisation (burnout) but
not psychological morbidity. Diminished personal
accomplishment was associated with higher
levels of psychological morbidity
Conclusion: In the sample of substance misuse professionals
studied, rates of psychological
morbidity and burnout were high, suggesting a higher level of
vulnerability than in other health
professionals. Furthermore, pathways to psychological
morbidity and burnout are partially related.
Therefore, targeted response is required to manage stress,
burnout and psychological morbidity
among substance misuse professionals. Such a response should
be integral to workforce
development.
Background
Since the introduction of the United Kingdom Govern-

ment's Drug Strategy in 1998, substance misuse services
have expanded with increases in funding available from
central government as part of implementation of the drug
strategy [1]. The targets set in the strategy may have put
extra demands on substance misuse services with a likely
increase in job-related stress, burnout and associated psy-
chological morbidity.
Studies of stress and burnout in various occupational
groups and settings have been widely reported [2-4].
Published: 8 February 2008
BMC Health Services Research 2008, 8:39 doi:10.1186/1472-
6963-8-39
Received: 16 March 2007
Accepted: 8 February 2008
This article is available from:
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© 2008 Oyefeso et al; licensee BioMed Central Ltd.
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Creative Commons Attribution License
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BMC Health Services Research 2008, 8:39
Page 2 of 9
However, few studies have examined burnout in sub-
stance misuse workers. An earlier study of burnout among
substance misuse workers in the UK [5] revealed high
emotional exhaustion and high depersonalisation in this
population. In addition, very few studies have examined
work-related predictors of burnout in substance misuse
workers, and these have been limited to the addiction
workforce in the United States [6,7]. Similarly, many stud-
ies have been conducted on the prevalence and pattern of
psychological morbidity in different occupational groups
and settings [8-10]. Yet, very few have focused on psycho-
logical morbidity and its predictors in substance misuse
professionals.
There are pointers in the literature to the presence of high
occupational stress burnout and high psychological mor-
bidity among substance misuse professionals. Human
services, such as substance misuse practice, that entail rel -
atively low practitioner autonomy tend to be strongly
associated with high psychological morbidity [11]). Sec-
ondly, substance misuse practice has been associated with
high demands and low control over caseload and tasks
[5]. These circumstances are similar to the concept of job
strain that has been articulated by Karasek et al [12]. Fur -
thermore, Calnan et al [13] have demonstrated a strong
relationship between job strain and psychological mor-
bidity.

Determining the extent, pattern and predictors of burnout
and psychological morbidity among substance misuse
professionals can lead to major benefits such as:
• Improving job satisfaction and retention in the work-
force, given the significant negative relationship between
stress and job satisfaction
• Providing information that should assist employee sup-
port and the development of programmes to promote
employee well-being
• Helping employers address employee mental health
needs with a view to improving overall psychological
health and job performance.
The aim of this study was to determine the prevalence,
pattern and predictors of burnout and psychological mor-
bidity using data collected during the earlier stages of
implementation of the Government's ten-year drug strat-
egy.
The study objectives were to determine the prevalence of
burnout and psychological morbidity among substance
misuse service workers; the influence of demographic var-
iables, job characteristics and job stressors on burnout
and psychological morbidity; and examine the relation-
ship between burnout and psychological morbidity.
Methods
This study was designed to test the following hypotheses:
1. Age and gender would predict burnout and psycholog-
ical morbidity.

2. Job characteristics would predict burnout and psycho-
logical morbidity.
3. Job stressors would predict burnout and psychological
morbidity.
4. There would be a significant positive relationship
between burnout and psychological morbidity.
Maslach and Jackson's [14] definition of burnout was
adopted in this study. However, the three dimensions of
burnout, emotional exhaustion, depersonalisation and
diminished were examined separately. Psychological mor-
bidity was defined as scores on the General Health Ques-
tionnaire – 12 (GHQ-12) [15].
The data reported in this article were collected as part of a
cross-sectional postal survey of clinical staff of substance
misuse services in the former South Thames region of Eng-
land in 2000. Staff from private clinics were excluded
from this analysis. The survey questionnaire covered
many areas including demographic details, job character-
istics, measures of burnout, job stressors, visual analogue
scales of job stress and job satisfaction and psychological
morbidity. The relationships between job stress, burnout
and job satisfaction have been reported previously in the
development and validation of an occupational stress
scale among substance misuse professionals [16].
Subjects
The sample consisted of clinical staff working in substance
misuse services (statutory and non-statutory) in the
former South Thames (West) region of England. The sam-
pling frame was based on the number of services listed in
the directory of substance misuse services published by
health authorities. Secondly, the manager of each service

was requested to provide the number of current staff with
existing caseload. This mapping exercise yielded 280 staff
that were surveyed from 46 services. Staff from these serv-
ices provided a sample size of 194, yielding a response
rate of 69% (the number of respondents returning a ques-
tionnaire as a percentage of all identified clinical staff in
participating agencies), after a second wave that involved
a telephone reminder. The first wave of the postal survey
yielded a response rate of 52% after one month. We were
unable to determine the nature and magnitude of non-
Page 3 of 9
response bias because at the time of the study, there was
no information on the characteristics of substance misuse
clinical staff in the region.
The mean age of respondents was 38 years (SD = 9.9). Par -
ticipants were 57% female and the following occupa-
tional groups were represented: Nurses (36%, n = 70);
drug/alcohol counsellors (29%, n = 56); social workers
(8%, n = 15); doctors (6%, n = 12); clinical psychologists
(3%, n = 6); and others (e.g., occupational therapist, pro-
bation officers, outreach workers, drug support workers,
etc: 18%, n = 35).
Dependent variables
The four dependent variables were emotional exhaustion
(EE); depersonalisation (DP) and diminished personal
accomplishment (PA) and psychological morbidity (PM).

The three dimensions of burnout were measured with the
Maslach Burnout Inventory (MBI) [17]. Using the norm
reported in the manual [17], respondents with the follow-
ing scores were classified as 'high' scorers and, therefore
fulfilled the criteria for burnout: EE ≥ 27; DP ≥ 13; and PA
≤ 31. Psychological morbidity was measured with the gen-
eral health questionnaire-12 (GHQ-12), scored using the
0-0-1-1 scoring format with scores ranging from 0–12.
Caseness for psychological morbidity was determined
using a cut-off of 4 [18]. Both measures are widely used
instrument for measuring burnout and psychological
morbidity, respectively.
Independent variables
The independent variables were demographic characteris-
tics; job characteristics and job stressors. The demographic
variables included in the analysis were age and gender.
Job characteristics were intensity of client contact (ICC:
number of hours of weekly contact) and tenure (number
of years of experience in substance misuse). Participants
were asked to indicate the extent to which a list of 112 job
stressors, obtained from the literature and from discus-
sions with a sample of clinical staff, gave them pressure
using a Likert-type scale (no pressure, slight pressure;
moderate pressure, considerable pressure, extreme pres-
sure).
Job stressors
Participants' response to the questions on job stressors
was subjected to internal consistent analysis (Cronbach
α). Items that resulted in a decrease in α were excluded
from further analysis. This procedure yielded 68 internally
consistent items.
Principal component analysis, with varimax rotation, was
used to reduce the number of internally consistent job

stressors experienced by respondents to manageable types
or factors. The Scree test was used to determine the
number of factors (or types). A stressor belonged to a fac-
tor if it returned a factor loading ≥ 0.40. Furthermore, a
job stressor was excluded from the rotated factors if it had
a factor loading ≥ 0.40 loaded on two or more factors [19].
The principal component analysis yielded three orthogo-
nal factors. Factor 1 termed 'Alienation' consisted of 15
stressors. Examples of stressors in this factor were "Lack of
support from senior staff"; "Feelings of isolation"; and
"Role ambiguity." Factor 2, termed 'Case complexity',
consisted of 13 stressors with the following examples:
"Manipulative clients"; "Demanding clients"; and "Deal-
ing with clients with overdose." Factor 3, termed 'Ten-
sion" consisted of 15 stressors such as "Conflicting
demands of my time at work by others"; Having too little
time to do what is expected of me"; and "Work overload"
(Additional file 1).
The three job stressor variables were categorised into two
levels. Participants whose scores were greater than or
equal to the mean on each factor were classified as experi -
encing high levels of Alienation, Case complexity and
Tension, respectively. Participants that score below the
mean were classified as experiencing low levels of each
category of job stressor.
Statistical analysis
Cronbach's α was used to assess internal consistency of
validated measures – MBI and GHQ-12 (Likert-type
scale).
Prior to logistic regression analysis, univariate odds ratio
was used to determine the relationship between categori-

cal independent and dependent variables. The relation-
ship between interval independent variables (ICC and
tenure) and categorical dependent variables was deter-
mined using point-biserial correlation. Logistic regression
analysis was used to examine the association between
independent and the dependent variables. Using the Hos-
mer and Lemeshow [20] criterion, an independent varia-
ble was included in the logistic regression model if the
univariate odds ratio or point-biserial correlation had a p
value of 0.1 or less.
Dummy variables of occupational groups, with nurses as
the referent variable, were developed and introduced into
logistic regression as control variables. A p-value of < 0.05
was considered to indicate statistical significance. SPSS
version 15 was used for all statistical analyses.
Ethics approval
The Wandsworth Local Research Ethics Committee
approved this study.
Page 4 of 9
Results
Internal consistency of measures
The four dependent measures in the study had acceptable
internal consistency in the study sample: GHQ-12, Cron-
bach's α = 0.75; MBI EE subscale, α = 0.90; DP subscale, α
= 0.76; and PA subscale, α = 0.75.

Prevalence of psychological morbidity
The prevalence rate of psychological morbidity in the
sample was 82.3% (95% CI = 76.1–87.4). Male and
female prevalence rates were 82.4% (95% CI = 72.6–89.8)
and 82.2% (73.7–89.0), respectively.
Prevalence of burnout
The rate of burnout was as follows: high emotional
exhaustion (EE), 33.2% (95% CI = 26.5–40.4); high
depersonalisation (DP), 17.0% (95% CI = 11.9–23.2);
and diminished personal accomplishment (PA), 35.8%
(95% CI = 29.0–43.2). Male and female burnout rates
were as follows: Male high EE rate, 31.7% (95% CI =
21.9–42.9); female high EE rate 34.3% (95% CI = 25.3–
44.2); male high DP rate, 20.7% (95% CI = 12.6–31.1);
female high DP rate, 14.2% (95% CI = 8.1–22.3); male
low PA rate, 29.3% (95% CI = 19.7–40.4); and female low
PA rate, 41.0% (95% CI = 31.5–51.0).
Summary of dependent measures
There was no significant difference between occupational
groups on all dependent measures (Table 1).
Selection of potential predictors of psychological
morbidity
Univariate odds ratio, using the Hosmer & Lemeshow cri-
terion (p < = 0.1) revealed acceptable correlation coeffi -
cients between psychological morbidity (PM) and
Alienation (p = 0.07); Tension (p = 0.07); EE (0.02); DP
(0.1); and PA (0.009. Point-biserial correlation analysis
revealed significant positive relationship between PM and
age (p = 0.1); intensity of client contact (ICC: p = 0.07);
Table 1: Summary statistics of dependent measures by
occupational group

Occupation GHQ-12* EE DP PA
Nurses
Mean 5.6 21.9 8.2 33.0
SD 2.6 9.8 5.9 7.7
N 68 68 69 69
Social workers
Mean 71 26.1 9.2 33.7
SD 2.5 13.5 5.8 5.1
N 15 15 15 15
Doctors
Mean 6.4 19.3 6.6 30.7
SD 2.2 8.8 4.8 9.2
N 11 11 10 10
Clinical psychologists
Mean 5.7 29.4 6.2 35.8
SD 3.1 8.6 7.5 9.0
N 6 5 5 6
Drug and alcohol counsellors
Mean 5.7 21.4 6.1 35.4
SD 2.8 10.6 5.4 6.3
N 54 54 54 53
Other
Mean 6.1 21.7 7.7 33.1
SD 2.9 11.9 5.8 7.2
N 33 34 34 34
F statistic 0.9 (p = 0.48) 1.1 (p = 0.37) 1.2 (p = 0.31) 1.2 (p =
0.30)

* Scoring: 0-0-1-1
Page 5 of 9
and tenure (0.05). These variables were included in the
logistic regression model.
Selection of potential predictors of EE, DP and PA
Correlation between EE and the following variables met
the criterion for selection: Tension (p = 0.0001); Aliena-
tion (p = 0.0001); Case complexity (p = 0.04); and age (p
= 0.01). Correlation between DP and Tension (p =
0.0001); Alienation (p = 0.004); Case complexity (p =
0.001); age (p = 0.02); and tenure (p = 0.1) met the crite-
rion for selection. Finally, correlation between PA, age (p
= 0.1); and gender (p = 0.07) met the criterion for selec-
tion.
Five logistic regression models emerged from the findings
of the univariate analysis. These models were adjusted for
occupational groups and used to test the study hypothe-
ses:
1. Log [P(PM = 1)/P(PM = 0)] = b0+ b1Tension + b2Age +
b3ICC + b4Tenure.
2. Log [P(PM = 1)/P(PM = 0)] = b0 + b1EE + b2DP +b3PA.
3. Log [P(EE = 1)/P(EE = 0)] = b0+ b1Tension + b2Alienation
+ b3Case complexity +b4Age + b5Tenure.

4. Log [P(DP = 1)/P(DP = 0)] = b0+ b1Tension + b2Alienation
+ b3Case complexity + b4Age + b5Tenure.
5. Log [P(PA = 1)/P(PA = 0)] = b0+ b1Age + b2Gender.
The variables were coded as follows: Gender (0 = Male, 1
= Female); age (dummy variables were developed for
under-25s; 25–34; 35–44; referent = 45 and over); ICC
(categorised as low – below the mean = 0; and high –
mean and above = 1); Tenure (categorised as short –
below the mean = 0; and long – mean and above = 1);
Alienation (0 = low, 1 = high); Case Complexity (0, low,
1 = high); Tension (0 = low, 1 = high); PM (0 = low, 1 =
high); EE (0 = low, 1 = high); DP (0 = low, 1 = high);and
PA (0 = high, 1 = low).
Predictors of psychological morbidity and burnout
The first hypothesis, which predicted that age and gender
would predict psychological morbidity and burnout, was
partially confirmed. Gender did not predict psychological
morbidity and the three dimensions of burnout. How-
ever, age was a significant predictor of emotional exhaus-
tion. Compared to those aged 45 years and over,
participants aged below 25 years were seven times as likely
to experience high emotional exhaustion. However, there
was no association between age and psychological mor-
bidity and other dimensions of burnout (DP and PA)
(Table 2).
As stated in the second hypothesis, there was no evidence
that job characteristics (tenure and ICC) predicted psy-
chological morbidity and burnout. However, the third
hypothesis, which stated that job stressors would predict
psychological morbidity and burnout, was partially sup-
ported. High scorers on alienation and tension were thrice

as likely to experience emotional exhaustion as low scor -
ers on both independent variables. Furthermore, high
scorers on alienation were five times as likely to experi -
ence depersonalisation as low scorers (Table 2)
The fourth hypothesis that predicted a significant positive
relationship between burnout and psychological morbid-
ity was partially confirmed. Diminished personal accom-
plishment was the only burnout dimension that
significantly predicted psychological morbidity. Respond-
ents with diminished personal accomplishment were
about four times as likely to experience psychological
morbidity (Table 2)
Discussion
The findings of this study reveal that the prevalence of psy-
chological morbidity among substance misuse workers is
high (82%). The prevalence of burnout was not as pro-
nounced, with 33% of participants reporting high EE;
17% reporting high DP; and 36% reporting diminished
PA. The average EE, DP and PA scores in the study sample
were 22.1, 7.4 and 33.7, respectively. The EE score in our
sample was higher than that in most human services occu-
pational groups, e.g., teaching, 21.3; postsecondary edu-
cation, 18.6; social services, 21.4; and mental health, 16.9;
but similar to that in medicine, 22.2 [17]. Our findings,
therefore, strongly indicate that substance misuse profes-
sionals are more vulnerable to burnout than most human
services professionals. Furthermore, compared to nurses,
social workers were at higher risk of emotional exhaus-
tion. This is an observation that has not been previously
reported among substance misuse professionals.
One of the novel findings in this study is the identification
of three types of stressors among substance misuse profes-
sionals – Alienation, Tension and Case Complexity. The

constructs of alienation and tension are consistent with
the Job Demand-Control (JDC) model developed by Kar-
asek [21], while Case Complexity encompasses the Client
Demand subscale of the Addiction Employee Stress Scale
[16].
Identification of these three categories of stressors is use-
ful for two reasons. It helps to organise the wide range of
job stressors linked to substance misuse practice into
manageable segments. Secondly, it facilitates better
understanding of the link between job stressors and burn-
out by revealing the types of job stressors that are directly
associated with burnout. From this study, alienation and
Page 6 of 9
Table 2: Logistic regression models for psychological morbidity
and burnout
Dependent variable Multivariate predictors Wald χ2 P value
Adjusted OR 95% CI
Model 1
Psychological morbidity (GHQ-12) High level of Alienation
1.50 0.22 2.00 0.66–6.11
High level of Tension 0.13 0.72 1.19 0.47–6.11
Age: Under 25s 0.51 0.48 2.32 0.23–23.23-
Age: 25–34 years 1.40 0.24 0.53 0.18–1.52
Age: 35–44 years 0.04 0.85 0.90 0.30–2.69

Age: 45 year and over - - 1.00 -
Long tenure 0.56 0.46 1.39 0.59–3.30
High ICC 0.38 0.54 1.30 0.57–2.95
Social worker 2.04 0.15 4.95 0.55–44.28
Doctor 0.60 0.44 2.40 0.26–21.96
Clinical psychologist 0.02 0.89 1.19 0.11–12.64
Drug and alcohol counsellor 0.14 0.71 1.22 0.44–3.35
Other 0.44 0.51 0.70 0.24–2.03
Nurse - - 1.00 -
Model 2
Psychological morbidity (GHQ-12) High emotional exhaustion
3.47 0.06 2.83 0.95–8.43
High depersonalisation 0.11 0.74 1.28 0.31–5.35
Diminished personal accomplishment 6.61 0.01 3.65 1.36–9.79
Social worker 1.11 0.29 3.22 0.37–28.19
Doctor 0.66 0.42 2.50 0.28–22.72
Other 1.15 0.28 0.57 0.20–1.59
Nurse - - 1.00 -
Model 3
Burnout: Emotional exhaustion High levels of Alienation 7.54
0.006 3.49 1.43–8.51
High levels of Tension 4.46 0.04 2.65 1.10–6.52
High levels of Case complexity 0.04 0.85 1.10 0.41–2.94
Long tenure 0.002 0.96 1.02 0.43–2.40
Age: Under 25s 4.43 0.04 7.15 1.15–44.65
Age: 25–34 years 1.55 0.21 2.02 0.67–6.11
Age: 35–44 years 0.62 0.43 1.54 0.53–4.45
Age: 45 & over - - 1.00 -
Social worker 5.53 0.02 4.82 1.30–17.87
Doctor 0.03 0.87 0.86 0.14–5.46

Other 2.07 0.15 2.18 0.75–6.312
Nurse 1.00
Model 4
Burnout: Depersonalisation High levels of Alienation 1.30 0.25
1.87 0.64–5.48
High levels of Tension 5.68 0.02 4.57 1.31–15.91
High levels of Case complexity 1.85 0.17 2.07 0.73–5.86
Long tenure 2.31 0.13 0.43 0.15–1.27
Age: Under 25s 2.25 0.13 5.45 0.60–48.90
Age: 25–34 years 0.92 0.34 2.14 0.45–10.14
Age: 35–44 years 1.78 0.18 2.78 0.62–12.45
Social worker 0.05 0.83 1.22 0.20–7.34
Doctor 0.56 0.45 0.38 0.03–4.73
Clinical psychologist 0.72 0.40 0.33 .003–4.25
Other 0.03 0.86 1.12 0.33–3.84
Nurse - - 1.00 -
Page 7 of 9
tension emerged as strong predictors of emotional
exhaustion and
depersonalisation.
Although job stressors (alienation and tension) predicted

two dimensions of burnout, none of these factors was
directly linked to psychological morbidity. This finding
contrasts with that of Calnan et al [9] where high demand,
low control and low support – concepts similar to aliena-
tion and tension in our study – predicted higher GHQ
scores. Rather diminished personal accomplishment,
which was independent of job stressors, predicted psycho-
logical morbidity. This finding suggests that individual
differences – personality, motivation, attitudes, need for
achievement, mental health history- rather than job-
related variables alone are more likely to predict psycho-
logical morbidity. Furthermore, there is an indication that
substance misuse practice involves psychological
demands that are different from workload, dealing with
complex patients, etc. These demands may include the
practitioner's feeling of self-worth, role adequacy and per-
sonal achievement, which are often associated with
opportunities to develop new skills and the use of a vari -
ety of skills [22,23].
Limitations
There are limitations of this study that are mainly linked
to the study design and sample. Firstly, the study adopted
a cross-sectional design, which prevented conclusion
regarding causality. A longitudinal design is better able to
determine the causal relationship between job-related fac-
tors, burnout and psychological morbidity. McManus et al
[10] have demonstrated the usefulness of longitudinal
designs in burnout studies. Secondly, it was difficult to
exclude the influence of social desirability that is often
associated with self-administered questionnaire surveys.
However, this is a limitation shared with many other stud-
ies of burnout and psychological morbidity. Thirdly, the
reasons for non-response and the influence of age, gender
and professional group on response rate were not exam-

ined. Consequently, it is plausible that the effect of non-
response bias could have affected the results as non-
responders may have differed in their experience of job
stress, psychological morbidity and burnout. Another lim-
itation is the age of the data, which may not reflect current
patterns of psychological morbidity and burnout in the
group studied.
Study implications
Despite these limitations, the findings have provided use-
ful information on job-related risks of burnout and psy-
chological morbidity that can assist in the development of
employee well-being programmes, and eventually
enhance performance among substance misuse profes-
sionals. Furthermore, the findings can serve as a baseline
for monitoring changes over time in the prevalence and
pattern of burnout and psychological morbidity in the tar-
get group, by conducting repeated cross-sectional surveys
in similar cohorts.
In terms of substance misuse practice, the findings should
assist relevant policy makers in maintaining a healthy
workforce. Firstly, there is evidence in this study that sub-
stance misuse professionals aged 25 years and below are
at risk of emotional exhaustion. Therefore, there is a need
for managers to provide adequate support for young prac-
titioners who are likely to be new to the demands and
challenges of substance misuse practice. Secondly, the
strong association between personal accomplishment and
psychological morbidity proves the need for employers to
enhance staff competencies through professional devel -
opment; this inevitably leads to improved self-esteem.
Finally, the significant association between alienation,
tension and the two burnout dimensions (EE and DP)
suggests the need for employers to develop a work-based
stress reduction programme that can assist substance mis-

use professionals in developing personal stress coping
strategies.
Model 5
Burnout: Diminished Personal
accomplishment
Gender 2.42 0.12 1.67 0.88–3.18
Age: Under 25s 0.70 0.40 1.86 0.43–7.94
Age: 25–34 years 0.01 0.93 1.04 0.47–2.27
Age: 35–44 years 0.12 0.73 0.86 0.37–2.02
Age: 45 and over - - 1.00 -
Social worker 2.43 0.12 0.34 0.09–1.32
Doctor 0.002 0.97 1.03 0.26–4.09
Other 0.02 0.90 0.95 0.40–2.22
Nurse - - 1.00 -
Table 2: Logistic regression models for psychological morbidity
and burnout (Continued)
Page 8 of 9
Still, there are many unresolved questions about the rela-
tionship between demographic characteristics, job charac-
teristics, job stressors and psychological morbidity. These
include finding out the role of potential moderating vari -
ables such as personality, motivation, job attitudes, and

mental health history. It is also possible that these varia-
bles are associated with burnout. These and other ques-
tions should be explored in future research on job stress
among substance misuse professionals.
Conclusion
In the sample of substance misuse professionals studied,
rates of psychological morbidity and burnout were high,
suggesting a higher level of vulnerability than in other
health professionals. Furthermore, pathways to psycho-
logical morbidity and burnout are partially related. There-
fore, targeted response is required to manage stress,
burnout and psychological morbidity among substance
misuse professionals. Such a response should be integral
to workforce development.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
AO wrote the manuscript, analysed the data, interpreted
the results and co-ordinated the study.
CC collected data, interpreted the results and revised the
article for intellectual content.
RF was involved in study design, data interpretation and
revising the article for intellectual content.
AO is the study guarantor.
This article is a product of the "Professionals Help Your -
self" (PHY) programme being developed at St George's,
University of London

Additional material
Acknowledgements
We are grateful to the substance misuse professionals that
participated in
this study and to the peer reviewers for their constructive
comments. The
comments of the statistical reviewer were particularly useful
and for these
we are grateful.
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Additional file 1
Principal component analysis of job stressors with varimax
rotation. The
table describe three categories of job stressors – alienation, case
complexity
and tension.
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stress, coping strategies, and
burnout among abuse-specific
counselors
Sam Loc Wallace
Jayoung Lee
Sang Min Lee
The purpose of this study is to investigate whether effective
coping strategies play an
important role to reduce burnout levels among sexual or
substance abuse counselors.
The authors examined whether coping strategies mediated or
moderated relations
between job stress and burnout in a sample of 232 abuse-
specific counselors. Results
indicated that self-distraction and behavior disengagement

coping strategies medi-
ated the relationships between 3 job stress variables (workload,
role conflict, and
job ambiguity) and burnout. Although venting and humor
coping strategies positively
moderated the relationship between role ambiguity and burnout,
active coping strate-
gies negatively moderated the relationship between workload
and burnout.
Although the counseling profession can have many rewards,
burnout can be a potential
outcome of providing counseling and psychotherapy. Burnout is
conceptualized as a
psychological syndrome in response to chronic emotional and
interpersonal stress
on the job and is most widely defined by the dimensions of
exhaustion, deperson-
alization, and inefficacy (Maslach, Schaufeli, & Leiter, 2001).
Much of the focus of
burnout research has been with individuals who work in the
human services field
(Vredenburgh, Carlozzi, & Stein, 1999). There has been
increasing recognition and
study of this problem in the counselors who are working with
sexual offenders and
substance abuse clients. It is believed that burnout is a potential
response to the
emotional stress of working with others who are troubled
(Everall & Paulson, 2004).
Several studies (Pearlman, 1996; Pearlman & Saakvitne, 1995;
Rich, 1997) reported
that abuse-specific counselors working with sexual offenders
and substance abuse
clients would exhibit evidence of cognitive disruptions at levels
higher than those of

a criterion reference group of general mental health
professionals. The impact on the
counselor is believed to have direct adverse consequences to the
clients they serve.
Burnout may emerge in session as a loss of empathy, respect,
and positive feelings for
abuse-specific clients; more therapeutic gridlock; and boundary
violations (Pearlman
& Maclan, 1995; Skorupa & Agresti, 1993). When the mental
health professional
becomes burned out, she or he may exhibit behaviors that affect
the quality of care
• • • •
Sam Loc Wallace, Department of Rehabilitation, Human
Resources and Communication Disorders,
University of Arkansas, Fayetteville; Jayoung Lee and Sang
Min Lee, Department of Education, Korea
University, Seoul, Korea. Correspondence concerning this
article should be addressed to Sang Min
Lee, Department of Education, College of Education, Korea
University, Anam-dong, Seongbuk-gu,
Seoul, Korea (e-mail: [email protected]).
© 2010 by the American Counseling Association. All rights
reserved.
journal of employment counseling • September 2010 • Volume
47 ' 111
provided to clients (McCarthy & Frieze, 1999). Because the
consequences of burn-
out can ultimately impair clients, it is clearly an issue of
professional and ethical

behavior to develop awareness of burnout (American
Counseling Association, 2005;
Everall & Paulson, 2004).
The relationships between people and work have been
recognized as a catalyst for
potential problems (Maslach et al., 2001). Adverse emotional
and behavioral sequelae
of job satisfaction and burnout for helping professionals have
been identified in several
studies (Bingham, Valenstein, Blow, & Alexander, 2002; Kirk-
Brown & Wallace, 2004;
Malach-Pines & Yafe-Yanai, 2001). The importance of studying
burnout within an
organizational context has been suggested by several
researchers (Emerson & Markos,
1996; T D. Evans & Villavisanis, 1997; Malach-Pines & Yafe-
Yanai, 2001; McCarthy
& Frieze, 1999). Job-related factors have been demonstrated to
affect counselors' levels
of burnout, with counselors in institutional settings being more
vulnerable to burnout
(Färber, 1990; Rosenberg & Pace, 2006; Trudeau, Russell, de la
Mora, & Schmitz,
2001; Yu, Lee, & Lee, 2007). Higher rates of emotional
exhaustion and depersonali-
zation were found in counselors working in community agency
settings versus those
in private practice, where it is believed that counselors are able
to regulate their job-
related stress easier because of working outside of a
bureaucratic hierarchical system
(Rosenberg & Pace, 2006). These findings are consistent with
the Job Demand-Control
(JD-C) model (Karasek, 1979) that suggests that job control
protects the individual

from problematic and damaging work environments. Models of
job environment and
the subsequent work-life have been proposed to play a central
role in the process of
burnout (Maslach et al., 2001). The interaction of these factors
and personal charac-
teristics contribute to a rich matrix of considerations for
developing burnout. Within
the expanded conceptualization of burnout, the work—life and
job stress framework
can augment the understanding of burnout.
Coping strategies are the ways in which individuals choose to
respond to stressful
situations (Welbourne, Eggerth, Hartley, Andrew, & Sanchez,
2007). Parkes (1994)
suggested that personal characteristics such as coping strategies
can mediate or
moderate relations between job demands (stressors) and job
strains (burnout symp-
toms). Individual differences in coping strategies have been
theorized to derive
from traditional personality dimensions and have been
supported in several studies
(Armstrong-Strassen, 2004; Carver, Scheier, & Weintraub,
1989; McCormick, Dowd,
Quirk, & Zegarra, 1998). Effective coping strategies may play
an important role in
reducing stress levels and increasing job satisfaction.
Welbourne et al. (2007) reported
that using nonavoidant coping strategies was associated with
higher job satisfaction
rates. Avoidant coping strategies have also been shown to be
related to increased
emotional exhaustion and decreased personal accomplishment
(G. D. Evans, Bry-

ant, Owens, & Koukos, 2004). Increasing the understanding of
the role of various
coping strategies on the relations between job stress and
burnout can help identify
effective coping skills to reduce exhaustion and
depersonalization and increase a
sense of personal competence and efficacy (G. D. Evans et al.,
2004).
The purpose of this study is to examine the relationships among
organizational job
stress, coping strategies, and burnout. We examined whether the
function of coping
strategies mediated or moderated relations between job stress
and counselor burnout.
112 journal of employment counseling • September 2010 •
Volume 47
Specifically, using the Baron and Kenny's (1986) mediation and
moderation model,
we analyzed for identifying mediating and moderating
relationships between coping
strategies and counselor burnout as they relate to types and
severity of job stress as
perceived by abuse-specific counselors. This study is innovative
in that it identifies
the role and function of coping strategies as mediating and
moderating factors in
relation to job stress and counselor burnout.
METHOD
Participants

The participants were 232 abuse-specific counselors (i.e., either
sexual abuse
counselors or substance abuse counselors). Participants in the
study were col-
lected through a web-based survey or by mail. An e-mail
containing a link to the
survey and measures was sent to two electronic mailing lists;
one with a focus on
sex offender treatment and research (Association for the
Treatment of Sexual Abus-
ers electronic mailing list and one with a focus on maltreatment
and victim issues
[Prevent—Connect]). Additionally, e-mails were sent to
substance abuse treatment
facilities located on the Substance Abuse and Mental Health
Services Administration
facility locator webpage. Of the hard copy surveys, 120 were
mailed to treatment
facilities or individual practitioners that were identified to work
in one of the three
areas of treatment specialty. Facilities and practitioners were
identified through a
web search of programs and practitioners who were identified as
having a treat-
ment focus in one or more of the respective categories (e.g.,
certified sex offender
treatment providers in Texas, rape crisis centers, substance
abuse programs). Of
the aforementioned surveys, 44 were returned for review
making the response rate
36.67%. Included in the sample were participants from 35 states
as well as seven
other countries (Japan, France, India, Israel, Canada, Australia,
and the United
Kingdom; n - 21). The mean age of the sample was 42.96 years

(SD = 11.94, range
= 23—76 years). Of the 232 participants included in the study,
71.4% were women
and 28.4% were men. The racial/ethnic composition of the
participants was 93.5%
European American, 3.9% Asian American, 1.3% African
American, 0.9% Indian
American, and 0.4% Hispanic American. These individuals had
been working in their
respective counseling organizations for an average of 10.71
years {SD — 7.51). Their
main discipline fields were social work (32.1%), mental health
(17.7%), counselor
education (5.6%), rehabilitation counseling (1.9%), and others
(42.1%). Also, this
sample is composed of master-level counselors (63.6%),
doctoral-level counselors
(21.8%), graduate counselors (11.1%; i.e., nonlicensed
counselors with a bachelor's
degree), and specialist counselors (3.1%; i.e., counselors with
an educational specialist's
degree such as Ed.S.). (Percentages may not total 100% because
of rounding.)
Instruments
Job Stress Scale (JSS; Caplan, Cobb, French, Van Harrison, &
Pinneau, 1975). The
JSS is a 13-item self-report questionnaire that measures the
frequency with which
47 113

an individual experiences four dimensions of job stress: (a)
Workload, which measures
the quantitative aspect of work overload resulting from time
pressures (e.g., "How often
does your job leave you with little or no time to get things
done?"); (b) Role Conflict,
which is a state in which rationally incompatible demands are
made upon the individual
by two or more persons whose jobs are functionally
codependent with the individual's
job (e.g., "How often do persons equal in rank and authority
over you ask you to do
things which conflict?"); (c) Role Ambiguity, which is a state in
which a person has
inadequate information to perform their role in an organization
(e.g., "How often are
you clear on what your job responsibilities are?"); and (d) Lack
of Utilization, which is
a stress factor related to underutilization of previously acquired
skills in carrying out
tasks required on the job (e.g., "How often can use the skills
from previous training?").
Individuals respond to items using a 7-point Likert-type scale
ranging from 1 {never)
to 7 {always). The four-factor structure was confirmed in a
study conducted by Hamel
and Bracken (1986) and was additional support for the
contention that job stress is a
multidimensional phenomenon. In this study, Cronbach's alphas
of .90, .81, .69, and
.83 were obtained, respectively, for the Workload, Role
Conflict, Role Ambiguity, and
Lack of Utilization JSS subscales.
Brief COPE (Coping Orientations to Problems Experienced)
Inventory (Carver,

1997). The Brief COPE Inventory is a 28-item self-report
questionnaire that assesses
an individual's cognitive and behavior coping strategies. It is an
abbreviated ver-
sion of the COPE Inventory (Carver et al., 1989), which has
problems regarding the
length and redundancy of the full instrume nt as well as the
overall time burden of
the assessment protocol. The Brief COPE Inventory produces
distinct scores for each
of the 14 coping strategies: (a) active coping, (b) planning, (c)
use of instrumental
support, (d) religion, (e) venting, (f) positive reframing, (g)
humor, (h) acceptance,
(i) use of emotional support, (j) self-distraction, (k) denial, (1)
behavioral disengage-
ment, (m) self-blame, and (n) substance use. Individuals
respond to iems using a
4-point Likert-type scale ranging from 0 (/ haven't been doing
this at all) to 3 {I've
been doing this alot) to express the frequency of use for each of
the coping behaviors.
In this study, the Cronbach's alpha achieved for all items of the
inventory was .78.
Counselor Burnout Inventory (CBI; Lee et al., 2007). The CBI
is a 20-item self-
report questionnaire that measures various levels of burnout.
The CBI provides
norm-referenced measures of a counselor's burnout syndrome on
five factorially
derived burnout dimensions: Exhaustion, Incompetence,
Negative Work Environment,
Devaluing Client, and Deterioration in Personal Life. Its focus
on the counselor's
work environment is unique to this inventory. This unique

component corresponds
with recent counseling burnout literature that accentuates the
role one's workplace
environment plays in promoting burnout (Azar, 2000; Maslach,
2005; Osborn, 2004;
Savicki & Cooley, 1981; Thompson, 1999). In this study, the
CBI total score was
used to assess the overall level of a counselor's burnout.
Individuals respond to items
using a 5-point Likert-type scale (1 = never true; 5 = always
true). The CBI contains
items reflecting characteristics of feelings and behaviors that
indicate various levels
of burnout. Lee et al. (2007) reported alpha coefficient total
scores of .88. Support
for construct validity was obtained through exploratory factor
analysis that identified
a five-factor solution and a confirmatory factor analysis with all
goodness-of-fit in-
Volume 47
dexes also indicating an adequate fit to the data (Lee et al.,
2007; Yu, Lee, & Nesbit,
2008). In this study, the Cronbach's alpha achieved for all items
of the CBI was .88.
Data Analyses
In this study, 19 variables were investigated: four variables
rating perceived severity of
job stress, 14 variables rating coping strategies, and one
variable rating level of counselor

burnout. We analyzed the relationships among these variables
by using multiple regression/
correlation analyses by the Baron and Kenny (1986) model (i.e.,
mediation and moderation
analyses). Specifically, we examined whether the function of
coping strategies mediated
between job stress and counselor burnout. The test for
mediation in this study involved
evaluating if the influence of job stress on counselor burnout
manifests itself through the
types and severity of the counselor's coping strategies; also, we
analyzed whether coping
strategies moderated the relationship between job stress and
burnout. The test for modera-
tion in this study involved evaluating the 56 interactions
between four subscales of the JSS
(predictors) and 14 types of coping strategies (moderators) on
counselor burnout (criterion
variable). Namely, in our analysis, we identified mediating and
moderating relationships
between coping strategies and counselor burnout, as they relate
to types, and severity of
job stress, as perceived by abuse-specific counselors. All data
were analyzed using SPSS
(Version 15.0), and all significance values shown were based on
two-tailed tests.
RESULTS
To test the hypothesis that 14 types of coping strategies would
mediate the relationship
between four types of job stress and counselor burnout, the
three-step tests of media-
tion suggested by Baron and Kenny (1986) were used. In this
study, the three-step
test for mediation involved (a) regressing the criterion variable

(counselor burnout) on
the predictor variables (subscales of the JSS), (b) regressing the
mediators (scales of
the Brief COPE Inventory) on the predictor variables (subscale s
of the JSS), and (c)
regressing the criterion variable (counselor burnout) on both the
predictors (subscales
of the JSS) and mediators (scales of the Brief COPE Inventory).
First, the relationships between subscales of the JSS (predictor
variables) and counselor
burnout (criterion variable) were significant, F(4, 203) -
29.50,/> < .01. Significant main
effects were shown for Workload (ß = .40,p < .01), Role
Conflict (ß - .77, p < .01), Role
Ambiguity (ß = .53, p < .05), and Lack of Utilization (ß = .60, p
< .01) on counselor bum-
out. These results fulfilled the mediation criteria in the first
step of Baron and Kenny's
(1986) model. Second, a correlation analysis was used to
measure the relationship be-
tween perceived severity of four types of job stress and 14 types
of coping strategies. Nine
mediators (i.e., self-distraction, active coping, denial, substance
use, use of instrumental
support, behavioral disengagement, planning, humor, and self-
blame) were statistically
significantly correlated with at least one of the predictor
variables. However, five media-
tors (i.e., use of emotional suppjort, venting, positive reframing,
acceptance, and religion)
were not statistically significantly correlated with any predictor
variables. Additionally, a
multiple regression analysis was used to test the relationship
between significant variables
in the second step (seK-distraction, active coping, denial,

substance use, use of instrumen-
47 115
tal support, behavioral disengagement, planning, humor, and
seK-blame variables) and
counselor burnout (the criterion variable). Among nine
mediators, only seven mediators,
self-distraction (ß = .16, p < .05), denial (ß = .12, p < .05),
substance use (ß = .15, p <
.05), behavioral disengagement (ß = .33, p < .01), planning (ß =
.33, p < .01), humor (ß
= .14,p < .05), and self-blame (ß = .13, p < .05), were
statistically significant. Therefore,
when considering these results, active coping and use of
instrumental support of coping
strategies were not considered for further analysis in the third
step.
In the third step, a test of the additional variance explained by
the mediators (seven •
coping strategies: self-distraction, denial, substance use,
behavioral disengagement,
planning, humor, and self-blame variables) in addition to four
job stress variables were
significant, F(9,190) = 13.65, p < .01, AR^ = .16. As shown in
Table 1, the follow-up
tests indicated that greater workload, role conflict, and role
ambiguity and greater
self-distraction and behavioral disengagement uniquely
predicted more counselor
burnout, i(197) = 2.62,p < .05 and i(197) = 3.74,p < .01,
respectively. More important,

complete mediation was observed because the predictor variable
(job ambiguity) was
not significantly related to the criterion variable (counselor
burnout) in the presence
of the mediators (seK-distraction and behavioral
disengagement). In addition, the re-
lationship between two predictor variables (workload and role
conflict) and criterion
variable (counselor burnout) were partially mediated by two
mediator variables (self-
distraction and behavior disengagement) because the effect on
counselor burnout of
two job stress variables (workload and role conflict) was
substantially decreased (see
Table 1). When applying Sobel's (1982) mediation test to
determine if the amount of
mediation was significant, the self-distraction variable partially
mediated the rela-
TABLE 1
Multiple Regression Anaiysis of Counselor Burnout (Criterion
Variable)
Predicted by Coping Strategies (Mediator Variables) and
Job Stress (Predictor Variables)
Variable
Step 1
Workload^
Role Conflict"
Role Ambiguity"
Lack of Utilization"
Step 2

Workload"
Role Conflict"
Role Ambiguity"
Lack of Utilization"
Self-Distraction'=
Denial
Substance Use"
Behavioral Disengagement"
Planning"
Humor*
Self-Blame"
B
0.42
0.78
0.64
0.42
0.32
0.71
0.36
0.34
0.98
0.85
0.79
2.08
0.52
0.23
0.46
SE
.11
.27

.21
.21
.10
.24
.18
.19
- .37
.62
.45
.56
.32
.28
.38
ß
.25
.22
.23
.14

.19
.20
.13
.11
.15
.08
.09
.22
.09
.04
.07
f
3.71**
2.90**
3.13**
1.97
3.23**
3.02**
1.97
1.81
2.62*
1.36
1.77

3.74**
1.65
0.83
1.22
AFP
.39
.16
fP
.39
.55
AF
30.86
13.65
^Job Stress Scale subscale. "Brief COPE (Coping Orientations
to Problems Experienced)
Inventory scale.
* p < . 0 5 . * * p < . 0 1 .
Volume 47
tionship between workload and counselor burnout (Z = 2.25, p <
.05). In addition,
behavior disengagement partially mediated the relationship
between workload and
counselor burnout [Z = 3.49, p < .01) as well as the relationship
between role conflict

and counselor burnout {Z = 3.53, p < .01).
Next, we tested the altemative hypothesis that coping strategies
moderated the relation-
ship between job stress and counselor bumout. A moderator is a
variable that changes the
relationship between a predictor variable and a criterion
variable (Frazier, Tix, & Barron,
2004). The main purpose for identifying and constructing
moderators is to increase pre-
dictive effectiveness (Abrahams & Alf, 1972). The moderator
model tested the effects of
four types of job stress (predictors) and the 14 types of coping
strategies (moderators) as
well as their interactions (e.g.. Workload X Active Coping) on
counselor bumout (criterion
variable). For these tests, both the amount of variance (/? :̂
effect size) accounted for by
job stress and coping strategies and their interactions and the
statistical significance of the
change in F produced by entering the job stress and coping
strategies and their interac-
tions were considered. When the interaction increased the R^ by
a statistically significcmt
amount, the two variables were moderating each other's
relationship with bumout. Table 2
summarizes only the significant moderating effects of coping
strategies on the relationship
between job stress (predictors) and counselor bumout (criterion
variable). Specifically, ac-
tive coping strategies moderated the relationship between
workload and counselor bumout
and increased the explained variance by a statistically
significant amount (ß = - . 1 7 , F =
16.59, AR^ = .03,p < .01). In addition, venting coping strategies
moderated the relationship

between role ambiguity and counselor bumout and increased the
explained variance by a
statistically significant amount (ß - .14, AF = 25.00, AR^ = .02,
p < .05). Humor coping
strategies also moderated the relationship between role
ambiguity and counselor bumout
and increased the explained variance by a statistically
significant amount (ß = .13, AF =
DISCUSSION
The findings of the current research contribute to an increased
understanding of the
relationship between coping strategies and counselor burnout as
these processes relate
to specific types of job stress among abuse-specific counselors.
There are several
TABLE 2
Moderating Effects of Coping Strategies on Job Stress
and Counselor Burnout
Variable
Workload" x Active Coping"
Role Ambiguity" x Venting"
Role Ambiguity" x Humor*
IE I ß
-.17*
.19**
.03*

I E 2 ß
.13*
.27**
.02*
I E 3 ß
.13*
.23**
.02*
Note. IE = interaction effect.
"Job Sress Scale subscale. "Brief COPE (Coping Orientations to
Problems Experienced)
Inventory scale.
*p< .05. **p< .01.
47 117
significant implications for theory, training, and practice for the
profession of abuse-
specific counseling. In support of the Job Demand—Resource
(JD-R) or JD-C models
that were the widely known theories used to explain the worker
burnout process
(Demerouti, Bakker, Nachreiner, & Schaufeli, 2001; Schaufeli
& Bakker, 2004), the

noteworthy outcome of the present research is that the job
demand variables (e.g.,
JSS subscales) increased counselor burnout while the resource
or control variables
(e.g., active coping strategies) helped reduce job demand
variables, thereby helping
to decrease the feeling of burnout among abuse-specific
counselors.
The JD-R or JD-C models conceptualize burnout not only as the
result of a period
of expending too much effort at work while having too little
recovery (Osborn, 2004)
but also as an erosion of engagement with the job (Schaufeli,
Salanova, Gonzales-
Roma, & Bakker, 2002). Results of the present study also
indicated that avoidant
emotional coping strategies, specifically self-distraction and
behavior disengagement,
mediated the relationship between three JSS subscales (Work
Load, Role Conflict, and
Job Ambiguity) and counselor burnout. In particular, the
complete mediation effect
was observed between job ambiguity and counselor burnout.
That is, the job stress
variables were positively related to greater levels of self-
distraction and behavior
disengagement coping strategies, and, in turn, greater self-
distraction and behavior
disengagement coping strategies were positively related to
greater burnout among
abuse-specific counselors. The interpretation of these findings
suggests that the re-
lationship between job stress and burnout is accounted for, in
part, by the function
of how negatively counselors cope with the stressful situation

(i.e., avoidant coping
strategies and erosion of engagement with the job).
In addition, the findings of the present study show some
moderation effects.
Emotional coping strategies, such as venting and humor,
positively moderate the
relationship between role ambiguity job stress and counselor
burnout. Significant
findings reflect that when abuse-specific counselors use venting
and humor coping
strategies and report higher role ambiguity, they have higher
levels of burnout.
Conversely, active coping strategies negatively moderate the
relationship between
work load stress and counselor burnout. Unlike emotional
coping strategies, even
when abuse-specific counselors reported higher work load in
their jobs, if they used
an active coping strategy, they reported lower levels of burnout.
These findings sug-
gested that investigating and discussing counselors' current
coping strategies toward
job stress may lead to preventing or alleviating their burnout
symptoms.
The present study supports the importance of understanding
coping strategies
that may alleviate abuse-specific counselors' burnout when they
are faced with the
stressful demands of their particular field of work. The findings
can be discussed
within a supervisory relationship in which the counselor can be
monitored and nur-
tured. Supervision can guide abuse-specific counselors to
understand their internal

mechanisms by helping them identify their current coping
strategies and by exploring
alternative effective coping strategies, especially for novice
abuse-specific counselors.
Yu et al. (2008) also stressed that supervision contributes
significantly in preventing
and alleviating counselors' burnout. Thus, ongoing supervision
is essential for both
those who are just entering the counseling profession and for
those who are more
experienced counselors. Clinical supervision helps novice
counselors to shape ap-
Volume 47
propriate coping strategies (i.e., active coping strategies based
on the results of the
present study) and also helps experienced counselors reduce the
existing ineffec-
tive coping strategies (i.e., self-distraction, behavior
disengagement, venting, and
humor based on the results of the present study) in situations
that are stressful in
their jobs. In other words, supervisors could discuss the
appropriate coping styles
to help address unsettled role conflict and ambiguity in the
work environment that
could potentially result in professional impairment. Thus,
identifying individual
counselors' dysfunctional and functional coping strategies could
be a valuable
supplemental supervisory tool that could lead to productive
discourse within the

supervisory relationship.
The findings of this study lend support to the expanded
conceptualization of
burnout that includes organizational sources. The findings also
increase explanatory
research on conceptual development of job stress models. The
social environment
and functioning of the workplace play an important role in how
people interact with
one another and, ultimately, how they perform their jobs
(Maslach, 2005). Organi-
zational development strategies may be of interest when
considering the role of the
organization on job stress and burnout. Diagnostic models
indicate that job design,
or the value of the work, should be supported by job inputs, or
organizational work
environment and culture, in order to produce the most effective
job outputs, or
products and results (Cummings & Worley, 2005). The most
salient organizational
variable contributing to burnout in this study was job
ambiguity. When abuse-specific
counselors are not clear on what their job responsibilities are,
what others in the
workplace expect of them, or how to define their standard of
performance, occupa-
tional stress will likely occur. It is important for supervisors
and administrators to
understand that clarity in the role of the abuse-specific
counselor is a key factor to
consider in job design and role assignment. Special attention
should be paid to the
roles of abuse-specific counselors in some settings, such as
residential treatment,

where conflict may arise when interacting with other
professionals who have different
job functions (e.g., nurses, physicians, teachers, and direct care
staff). These other
professional staff members may place demands on the counselor
that are contrary
to counselors' training, thereby increasing role ambiguity and
the likelihood for
burnout. Additionally, counselors who work with sex offenders
often have outside
stakeholders such as probation officers and officers of the
courts who may view the
counselor as an extension of law enforcement, thereby
potentially creating additional
expectations and job ambiguity. Attention to these types of
potential Stressors and
organizational pitfalls as well as how counselors cope with
these Stressors are im-
portant considerations for those in supervisory roles. Clarifying
the abuse-specific
counselor's role and performance of duties should be a routine
part of counselor job
orientation and ongoing training.
It is important to note that statistical mediation and moderation
were examined
in this study, and, as such, no causal inferences may be drawn
from this study
(Skowron, Wester, & Azen, 2004). In addition, all measures
were obtained by
self-report questionnaires, and participants were anonymous and
self-selected.
Thus, abuse-specific counselors may have responded in ways
that did not reflect
their actual attitudes and beliefs for various personal reasons.
Also, some abuse-

47 119
specific counselors who did not identify any job stress within
their work environment may
have judged their participation in this study to have litue impact
on them and chose not
to participate. Thus, future research could use multiple
measures (e.g., observation) to
assess the variables, thereby giving a clearer picture of the
long-term effects of job stress
and coping strategies on burnout. Considering the sample of the
current study, it is also
important to know the limitations of the generalizability of the
results. For example, the
skewed distribution of sex and race (European American,
female counselors) might have
an effect on the variability of the results. Finally, further
limitations of the study relate
to cultural implications of construct definition and our sample
selection. Healthy coping
strategies are contextually and socially defined and may vary
from culture to culture (Sue
& Sue, 2003). Ultimately, coping strategies cannot be viewed
apart from the influences of
race, ethnicity, and culture. For example, in some cultures (e.g.,
African American and
Hispanic), spiritual or religious coping may be strongly
emphasized, whereas in others
(e.g., European American), intrinsic sources of support (e.g.,
self-reliance) are highly
valued. Also, although some cultures encourage open disclosure
and expression of emo-

tion (e.g., Hispanic), others discourage such displays (e.g..
Native American; Sue & Sue,
2003). Further research with more diverse counselors (in terms
of sex and race) would
allow counseling researchers to determine if significant
similarities or differences exist
in job stress, coping strategies, and burnout levels between male
and female counselors
and between European American counselors and minority
counselors.
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COMPASSION FATIGUE, COMPASSION

SATISFACTION, AND BURNOUT: FACTORS
IMPACTING A PROFESSIONAL’S QUALITY OF LIFE
GINNY SPRANG and JAMES J. CLARK
College of Social Work, University of Kentucky, Lexington,
Kentucky, USA
ADRIENNE WHITT-WOOSLEY
University of Kentucky, Lexington, Kentucky, USA
This study examined the relationship between three variables,
compassion fatigue
(CF), compassion satisfaction (CS), and burnout, and provider
and setting char-
acteristics in a sample of 1,121 mental health providers in a
rural southern state.
Respondents completed the Professional Quality of Life Scale
as part of a larger
survey of provider practice patterns. Female gender was
associated with higher
levels of CF, and therapists with specialized training in trauma
work reported
higher levels of CS than nonspecialists. Provider discipline
proved to be an impor-
tant factor, with psychiatrists reporting higher levels of CF than
their non-medical
counterparts. When providers were compared using rural, urban,
and rural with
urban influence classifications, the most rural providers
reported increased levels
of burnout but could not be distinguished from their colleagues
on the CF and CS
subscales. Important practice, education, and policy

implications are noted for a
multidisciplinary audience.
American author James Baldwin (1963) wrote, ‘‘One can give
noth-
ing whatever without giving oneself, that is to say risking
oneself ’’
(p. 100). Risking exposure to vicarious trauma is an inherent
part
of the process when working with traumatized persons. The
empiri-
cal literature has documented mental health consequences of
professionals’ exposure to trauma patients, responses that differ
depending upon individual and contextual characteristics
specific
to the provider and the practice setting. This study explores
vari-
ables that might influence such responses to vicarious exposure
to
traumatic stress by examining compassion fatigue (CF),
compassion
Received 10 January 2007; accepted 23 January 2007.
Address correspondence to Ginny Sprang, University of
Kentucky, 3470 Blazer
Parkway, Suite 100, Lexington, KY 40509. E-mail:
[email protected]
259
Journal of Loss and Trauma, 12:259–280, 2007
Copyright # Taylor & Francis Group, LLC
ISSN: 1532-5024 print/1532-5032 online
DOI: 10.1080/15325020701238093

stress (CS), and burnout among mental health professionals in a
rural state. We also explore the individual, occupational, and
environmental factors that might impact the ways these
conditions
are expressed.
Literature Review
An expanding number of studies are examining the phenomena
of
CF and burnout in the helping professions. Early studies of
work-
related stresses were first conducted in business and industry,
and
subsequently in the human service professions. Maslach (1982)
defined burnout as ‘‘a syndrome of emotional exhaustion,
deperso-
nalization, and reduced personal accomplishment’’ (p. 3)
charac-
terized by cynicism, psychological distress, feelings of
dissatisfaction, impaired interpersonal functioning, emotional
numbing, and physiological problems (Fothergill, Edwards, &
Burnard, 2004). Burnout’s etiology is not significantly
associated
with worker countertransference or reactions to traumatic client
material but is associated with other workplace characteristics,
such as caseload size and institutional stress (Stamm, 1997).
McCann and Pearlman (1990a) expanded discussions of
countertransference reactions to include the term vicarious
trauma-
tization (VT), which describes the impact of repeated empathic
engagement with trauma survivors and associated cognitive,
sche-
matic, and other psychological effects. McCann and Pearlman

(1990b) and Pearlman and Saakvitne (1995) identified the
potential
for disruptions in therapists’ experiences of safety, trust, power,
esteem, intimacy, independence, and control. Associated symp-
tomatology includes anxiety, disconnection, avoidance of social
contact, becoming judgmental, depression, somatization, and
dis-
rupted beliefs about self and others (Cunningham, 2003;
Pearlman
& Saakvitne, 1995).
CF signifies more progressed psychological disruptions. This
term can be used interchangeably with secondary traumatic
stress
disorder (STSD) and is considered to be less stigmatizing
(Figley,
1995). The proposed continuum of responses ranges from com-
passion satisfaction to compassion stress and ends with CF
(Figley,
1995; Stamm, 2002b). Figley’s causal compassion stress and
fatigue
model (1995, 2002a, 2002b) points to the influence of nine
variables
implicated in the development of compassion fatigue, including
260 G. Sprang et al.
those related to traumatic material exposure and clinicians’
capacity for empathic engagement. He describes two positive
coping variables (sense of achievement and emotional disenga-
gement), while prolonged exposure, traumatic recollections, and
life disruption exacerbate stress reactions and may lead to the
development of compassion fatigue.

Literature reviews of work-related traumatic stress studies
reveal myriad terms to describe similar phenomena, leading
Stamm (1997) to opine that the controversy regarding secondary
trauma is not its existence but what it should be called. Studies
reflect commonalities and links among CF, VT, and secondary
traumatic stress (STS), so it is necessary to consider all
empirical
work regarding these concepts (Adams, Matto, & Harrington,
2001; Jenkins & Baird, 2002).
Few epidemiological studies exist regarding CF or secondary
trauma among the various groups of helping professionals routi -
nely exposed to trauma in the course of their work. Research on
STS symptomatology in child protective service (CPS) workers
suggests that this type of work carries high risk for transmission
of traumatic stress symptomatology (Dane, 2000; Pryce,
Shackelford,
& Pryce, 2007). Cornille and Meyers (1999) found 37% of study
participants exhibited clinically significant distress related to
CPS work. A study of community mental health workers found
that 17% met criteria for STSD and 18% exhibited significant
but subclinical levels of psychopathology (Meldrum, King, &
Spooner, 2002). Higher distress levels were found in studies of
dis-
aster response teams (Holtz, Salama, Cardozo, & Gotway,
2002).
Following the Oklahoma City bombing, 64.7% of trauma
workers
reported significant traumatic stress (Wee & Meyers, 2002). A
study of responders to the 9=11 attacks found 27% at extremely
high risk, 11.7% at high risk, and 15.4% at moderate risk for
developing CF (Roberts, Flannelly, Weaver, & Figley, 2003).
Empirical studies of burnout revealed it as an especially preva -
lent condition among helping professionals (Maslach & Jackson,
1984), with mental health professionals demonstrating higher

levels of burnout than primary health care workers (Imai,
Nakao,
Tsuchiya, Kuroda, & Katon, 2004; Korkeila et al., 2003).
Notably,
public-sector mental health providers were at higher burnout
risk
compared to their private-sector counterparts (Melamed, Szor,
&
Bernstein, 2001; Vredenburgh, Carlozzi, & Stein, 1999).
Compassion Fatigue, Compassion Satisfaction, and Burnout 261
Studies have indicated variables serving as risk or protective
factors for STS, CF, or burnout. As age increased, risk for STS,
VT, and burnout decreased (Adams et al., Harrington, 2001;
Nelson-Gardell & Harris, 2003; Vredenburgh et al., 1999), and
some
studies suggested that females were at significantly greater ris k
for
STS and VT (Brady et al., 1999; Kassam-Adams, 1999; Meyers
&
Cornille, 2002). Education mitigated burnout (Abu-Bader,
2000),
and years of professional experience were associated with a
decreased potential for VT (Cunningham, 2003; Pearlman &
MacIan, 1995). Another significant variable, personal trauma
history, was associated with increased risk for STS or VT
(Cunningham, 2003; Nelson-Gardell & Harris, 2003), though
some
studies suggest that personal coping styles and the ability to
construct
meaning in the face of stressful experiences may be truer
determi-
nants of Professionals’ emotional functioning (Follette,

Polusny, &
Milbeck, 1994; Ortlepp & Friedman, 2001). Researchers have
also
found that specialized training can serve a protective function
for
trauma counselors (Ortlepp & Friedman, 2002). Another study
examined the experiences of STS across mental health
disciplines
(psychologists, social workers, counselors) but did not find that
profession was a predictor of STS (Creamer & Liddle, 2005).
Exposure factors such as long work hours or length of assign-
ment and caseloads with high percentages of trauma patients
have
been associated with an increased incidence of STS and CF
(Boscarino, Figley, & Adams, 2004; Creamer & Liddle, 2005;
Meyers & Cornille, 2002). Organizational factors such as
support-
ive work environments and adequate supervision were noted to
mitigate the incidence of STS and burnout (Boscarino et al.,
2004; Korkeila et al., 2003; Ortlepp & Friedman, 2002; Webster
& Hackett, 1999). Autonomy and control seem to be mitigating
factors for burnout (Abu-Bader, 2000; Vredenburgh et al.,
1999),
while access to sufficient resources mitigated both burnout and
STS (Abu-Bader, 2000; Ortlepp & Friedman, 2001).
Workers with high caseloads of survivors of violent or human-
induced trauma (especially against children) seemed to be at
greater
risk for CF and STS (Creamer & Liddle, 2005; Cunningham,
2003). A study of mental health workers found that STS symp-
tomatology rates were higher for rural providers when compared
to their urban counterparts (Meldrum et al., 2002). Rohland
(2000) found that burnout among mental health directors did not

seem to be influenced by rurality, but he studied only a small
sample of nonclinicians.
In order to address the complexity of these phenomena, our
study explores the degree to which CF, CS, and burnout vary as
a
function of provider characteristics such as age, gender,
educational
level, licensure, years of experience, setting, and whether or not
the individual has specialized trauma training. Contextual
variables
such as organizational type and setting are also considered.
Method
Sample
A total of 6,720 licensed or certified behavioral health
providers
(psychologists, psychiatrists, social workers, marriage and
family
therapists, professional counselors, and drug and alcohol
counse-
lors) currently practicing in a rural southern state were invited
to
participate in the study. Individuals who were licensed by more
than one board were counted only once, leaving a useable pool
of 5,752 potential participants.
The remaining pool of providers received a mailed survey at
their place of residence along with a self-addressed postage-
paid

return envelope, a coupon for free training, and an informed
con-
sent document that outlined the purpose of the study, the
potential
benefits and risks of participation, and contact information.
Return
of the survey indicated the provision of informed consent. A
total
of 1,121 completed questionnaires were returned, which consti-
tuted 19.5% of the viable candidates for inclusion. Although
response rates to mailed surveys of 10%–25% are common
(Fox, Crask, & Kim, 1988), the rate of response to this study
may have been higher if budgetary restraints had not prohibited
follow-up reminders or remailings.
Measurement
The instrument used in this study was a 102-item survey
designed
to solicit information about the providers’ practice methods,
their
use of evidenced-based practices, their knowledge of event-
specific
responses in various populations (rural, children, the elderly),
barriers to effective treatment, and levels of compassion
fatigue,
compassion satisfaction, and burnout. This article deals with a
sub-
set of a larger study (Sprang, Craig, & Clark, 2006) and
specifically
explores the respondents’ professional quality of life and levels

of
compassion fatigue, compassion satisfaction, and burnout.
The Professional Quality of Life Scale (ProQOL) (Stamm,
2002b), a 30-item self-report measure, assesses risk of CF,
potential
for CS, and risk of burnout. Higher scores on the CF subscale
(10
items) indicate the respondent is at higher risk for compassion
fatigue. Higher scores on the CS subscale (10 items) indicate
the
respondent is experiencing better satisfaction with his or her
ability
to provide care (e.g., caregiving is an energy-enhancing experi-
ence, increased self-efficacy). Higher scores on the burnout
sub-
scale (10 items) indicate the individual is at risk of
experiencing
symptoms of burnout (e.g., hopelessness, helplessness). Alpha
scores range from .72 (burnout) to .80 (CF) and .87 (CS),
indicating
adequate internal consistency. The scale has good demonstrated
construct validity, and there is evidence that this version of the
measure reduced the known collinearity between compassion
fatigue and burnout (Stamm, 2005).
Providers were also asked to self-identify if they had specia-
lized training in trauma work and to specify the type of traini ng
they had received. To control for overconfidence bias, these
responses were compared with the ‘‘best-practice’’ guidelines
described previously. If the respondent identified specialized
trauma training in any of the identified empirically based
methods,
the respondent was categorized as having specialized trauma
train-
ing for the purposes of this study. Additionally, if the provider

reported professional experience in a trauma treatment center
(inpatient or outpatient), then the individual was character ized
as
a provider with specialized trauma training. Using this criterion,
the rate of agreement between study evaluators and respondent
self-identification was 73%. In general, respondents tended to
overidentify themselves as trauma specialists if they had
personal
histories that were positive for trauma exposure and if they had
related but non-trauma-related training experiences (i.e., ethics
training, training in the assessment and treatment of other
conditions such as depression or substance misuse).
A series of items aimed at identifying personal and professional
characteristics of each respondent were also included. These
questions solicited information about the provider’s age,
gender,
years of professional experience, discipline, highest degree
earned,
and work setting. Respondents were also asked to identify their
county
of practice so that rural and urban comparisons could be made.
Using the Beale code classification system (Butler & Beale,
1994), respondents were assigned a code of 0 to 9 that provided
a descriptor of their county of practice: metropolitan area of 1
million or more (0), fringe county of metropolitan area of 1
million
or more (1), county in metropolitan area of 250,000 to 1 million
(2),
county in metropolitan area of less than 250,000 (3), urban

popu-
lation of 20,000 or more adjacent to metro area (4), urban area
of 20,000 or more not adjacent to metro area (5), urban area of
2,500 to 19,999 adjacent to metro area (6), urban area of 2,500
to 19,999 not adjacent to metro area (7), completely rural area
of
less than 2,500 adjacent to metro area (8), and completely rural
areas of less that 2,500 not adjacent to metro area (9).
Results
Provider Characteristics
The average age was 45.22 years (SD ¼ 10.84), with a range
from
23 to 81 years of age. The majority of professionals (68.6%)
had
master’s degrees and, on average, the participants had 13.92
(SD ¼ 9.54) years of experience, with approximately 30% of
their
clients experiencing post-trauma distress. Over one third of the
respondents (35.8%) worked in community mental health
settings,
while 13.6% worked in other public agencies, 29.6% were in
private practice, 6.2% worked in inpatient facilities, 4.9%
worked
in private facilities, and 9.9% other worked in settings. Of the
1,121
respondents, 327 (30.4%) were male and 749 (69.6%) were
female.
This trend held true for every discipline but psychiatrists, who
were
overrepresented by males (at 52%) (v2 ¼ 8.98, df ¼ 5, p < .01).
Otherwise, there were no statistically significant differences in
age
(v2 ¼ .05, df ¼ 5, p ¼ .89), setting (v2 ¼ 1.95, df ¼ 4, p ¼

.178),
or caseload (v2 ¼ 3.26, df ¼ 3.62, p ¼ .09) considering
discipline.
Incidence of Compassion Fatigue, Compassion Satisfaction, and
Burnout
In general, this sample fared better on the ProQOL subscales
than
reported national norms (Stamm, 2005). The CF mean score of
10.64 in this sample was lower than the national mean of 13,
with
13.2% of the respondent pool in our sample scoring above the
suggested cutoff (75%). On the burnout subscale, the national
mean
is reported as 23, compared to our sample mean of 19.9. Again,
just over 13% scored above the cutoff on the burnout subscale.
The potential for CS was slightly higher in our sample than
reported national norms (39.3% vs. 37%), with almost half
(48.7%) of our sample scoring above the suggested cutoff of 41.
Although these national estimates are approximates, they pro-
vided an important contextual backdrop for subsequent
analyses.
Differences by Provider Characteristics
A multivariate analysis of variance (MANOVA) was conducted
on CS, CF, and burnout by gender (male vs. female). Tests of
homogeneity of covariance matrices using Box’s M test and
homogeneity of variance assessed by Levene’s test were all
non-

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