October 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Galek, K., Flannelly, K. J., Greene, P. B. and Kudler, T. "Burnout, secondary traumatic stress, and social support." Pastoral Psychology 60, no. 5 (October 2011): 633-649.
SUMMARY and COMMENT: Burnout and Secondary Traumatic Stress (STS) are certainly concerns among chaplains, and this study out of Healthcare Chaplaincy (New York, NY) explores how these professional issues may be related to social support and various work-related variables, via a survey of chaplains attending a joint conference of the Association of Professional Chaplains, the National Association of Catholic Chaplains, the National Association of Jewish Chaplains, and the Canadian Association for Pastoral Practice and Education.
Data were analyzed from 331 chaplains (of a convenience sample of 389 conference attendees). Measures included 40 items from the burnout and compassion fatigue subscales of the Compassion Fatigue Test [--see p. 640, and Related Items of Interest §1, below]; questions about work-related variables: the number of years of work in current position, the number of hours per week spent counseling trauma victims, and the number of hours per week spent counseling patients who were not trauma victims [--see p. 641]; four questions about social support: "How willing are the following people to listen to your work-related problems?" "How willing are the following people to listen to your personal problems?" "How easy are the following people to talk to?" and "To what degree can the following people be relied upon when things get tough at work?" [p. 641]; and questions regarding control variables for age, gender, education, and years of professional experience and work.
Results are organized clearly around four hypotheses.
In addition, data showed "that women and older people in our sample are less likely to exhibit burnout," and "[a]lthough education had no significant effect on symptoms of burnout, it was negatively associated with traumatic symptomology" [p. 645]. Among the limits of the study: while the findings suggest a general association between burnout and STS, "it remains impossible to ascertain whether burnout and vicarious trauma have a directional influence on each other" [p. 645]; though the authors believe that further longitudinal study could reveal, for instance, whether "STS may set the stage for burnout, or the two syndromes may have an additive effect on each other" [p. 645].
- Hypothesis #1: "...[B]urnout would be positively associated with the number of years chaplains worked in the same position, whereas STS would not be related to years worked in the same position...." [p. 639]
- SUPPORTED -- "This hypothesis was based on the notion that institutional policies and practices can strain personal resources, such as self- esteem, over time, because they impinge on personal autonomy. Since STS appears to develop rather rapidly, Hypothesis 1 further predicted that STS would not be related to years in current position nor to the institutional factors that are presumably captured by this measure. While no significant association between STS and years in current position was found, there was a non-significant association between the two variables, leaving open the question of whether the institutional variables that contribute to burnout might also contribute to STS to some extent." [p. 644]
- Hypothesis #2: "...[B]urnout, but not STS, will be positively associated with the number of hours per week working with non-traumatized clients...." [p. 639]
- WEAKLY SUPPORTED -- "[T]he association between the number of hours of non-trauma counseling and burnout is weak, at best." [p. 643] "However, about half of the chaplains in our sample reported a total of 20 counseling hours or fewer each week, which suggests that hours of counseling may not be an adequate measure of the amount of time they spend in direct care with patients." [p. 644]
- Hypothesis #3: "...STS, but not burnout, will be positively associated with the number of hours per week working with traumatized clients...." [p. 639]
- STRONGLY SUPPORTED -- "The findings provide convincing support for Hypothesis 3. ...These findings support the contention of other researchers and clinicians that working with traumatized clients can have unique negative consequences on psychological well-being.... Interestingly, although chaplains working in hospitals were not more prone to STS, they were more likely to spend more time per week working with traumatized clients." [p. 644]
- Hypothesis #4: "...[S]ocial support from institutional sources (supervisors and co-workers) and personal sources (family and friends) would be inversely related to both burnout and STS...." [p. 639]
- PARTIALLY SUPPORTED -- "Social support from family and friends was inversely related to burnout and STS, but support from co-workers was found to be only weakly related to burnout and unrelated to STS. " [p. 643] "Part of the reason that social support from supervisors/co-workers was only weakly related to burnout may be that chaplains have very few colleagues from their own profession at their work-sites, and their supervisors are often in other disciplines." [pp. 644-645]
Atop the value of the particular findings here, the article offers a very nice overview of pertinent research and an introduction to the concepts and dynamics of burnout, STS, and the effects of social support [pp. 633-639]. Chaplain readers should be challenged to think about interpersonal and institutional sources of stress, the role of one's need to feel accomplishment as part of self-esteem, the tendency toward over-functioning in the helping professions and the difficulty of finding affirmation in bureaucratic and hierarchical systems like hospitals, and differences between working with trauma and non-trauma patients. The bibliography is an extensive resource for follow-up reading in many areas, with 72 references, though these cover only up to 2005. [For a few post-2005 articles, see Related Items of Interest §2, below.] This study draws quite reasonably and insightfully upon much research that focuses on psychotherapists, trauma therapists and other counselors, as it paints a picture of forces that may affect chaplains. However, in doing so, it may apply to a greater extent to chaplains who function more as counselors than pastoral caregivers. It occurs to this reader that the place of compassion and empathy in the pastoral caregiving role may tend to be a larger factor than in a counseling role.
The authors conclude that "[t]he current pattern of results suggests an overall beneficial impact of being able to rely on friends and family during difficult times" and "[m]ore broadly, our results highlight the need for therapists and counselors to be attuned to not only their clients but also to their own inner dynamics" [p. 646], for the sake of both the professional and the client.
Suggestions for the Use of the Article for Discussion in CPE:
The extended introductory section [pp. 633-639] should be of general interest to students and generate good discussion simply around the basic concepts and the cited findings of other studies. One cited work, an article by Grosch & Olsen [--see Related Items of Interest §3, below], that makes possible connections to childhood development [p. 635], may fit well with other CPE activities that call for introspective analysis of personal history. Students at trauma centers might be able to relate especially to the dynamics of Secondary Traumatic Stress after even a short time in their program, and CPE Residents might relate to the dynamics of burnout after just their first unit. The sections on methodology and results might be a little daunting when it comes to the statistics involved, but the article is written straightforwardly enough so that it should be easy to follow the narrative of the findings and their significance. Regarding the major conclusion about the importance of social support, discussion could focus on what sources of support students are actually using to cope with stress, including the potentially crucial resource of their peer group. Though not addressed in the article, discussion might also consider how confidentiality restrictions may hinder the ways that chaplains seek social support. Ultimately, can students begin to identify and analyze factors at play when they feel symptoms associated with burnout or STS, and can they imagine how to formulate a corrective plan?
Related Items of Interest:
I. Our featured study used the burnout and compassion fatigue subscales (17 and 23 items each, respectively) of the Compassion Fatigue Test (which also contains a 26-item subscale for compassion satisfaction). The measure was first published in 1995 by Charles R. Figley, who is now a professor of Social Work at Tulane University and director of the Tulane University Traumatology Institute and Psychological Stress Research Program. Information about his work, including a list of articles and books, can be found via www.charlesfigley.com. [Note: not all links are maintained on the site.]
II. The bibliography of our featured article is a good source for further reading, but it does not extend beyond articles published in 2005. A few studies published since then which may be of interest are:
Levy, H. C., Conoscenti, L. M., Tillery, J,F., Dickstein, B. D. and Litz, B. T. "Deployment stressors and outcomes among Air Force chaplains." Journal of Traumatic Stress 24, no. 3 (June 2011): 342-346. [This study is out of the National Center for PTSD, VA Boston Healthcare System. (Abstract:) Military chaplains are invaluable caregiver resources for service members. Little is known about how chaplains respond to the challenge of providing spiritual counsel in a warzone. In this exploratory study, 183 previously deployed Air Force chaplains completed an online survey assessing operational and counseling stress exposure, posttraumatic stress disorder (PTSD) symptoms, compassion fatigue, and posttraumatic growth. Despite reporting exposure to stressful counseling experiences, Air Force chaplains did not endorse high compassion fatigue. Rather, chaplains experienced positive psychological growth following exposure to stressful counseling experiences. However, 7.7% of Air Force chaplains reported clinically significant PTSD symptoms, suggesting that they are not immune to deployment-related mental health problems. Simultaneous regression analyses revealed that counseling stress exposure predicted compassion fatigue (beta = .20) and posttraumatic growth (beta = .24), suggesting that caretaking in theatre is stressful enough to spur positive psychological growth in chaplains. Consistent with findings from previous studies, hierarchical regression analyses revealed that operational stress exposure predicted PTSD symptom severity (beta = .33) while controlling for demographic variables.]
Spidell, S., Wallace, A., Carmack, C. L., Nogueras-Gonzalez, G. M., Parker, C. L. and Cantor, S. B. "Grief in healthcare chaplains: an investigation of the presence of disenfranchised grief." Journal of Health Care Chaplaincy 17, no. 1 (January 2011): 75-86. [This study addresses burnout in relation to its main topic of chaplains' disenfranchised grief. For more information, see the May 2011 Article-of-the-Month.]
Taylor, B.E., Flannelly, K. J., Weaver, A. J. and Zucker, D. J. "Compassion fatigue and burnout among Rabbis working as chaplains." Journal of Pastoral Care and Counseling 60, nos. 1-2 (Spring-Summer 2006): 35-42. [Note that this study is also out of HealthCare Chaplaincy in New York and shares a co-author with our featured article this month. (Abstract:) Compassion Fatigue, Compassion Satisfaction, and Burnout were studied in a convenience sample of 66 male and female Rabbis who work as chaplains and attended the annual conference of the National Association of Jewish Chaplains (NAJC) in 2002. Although Compassion Fatigue and Burnout were low among the survey participants, both measures were significantly higher among the women in the sample. Compassion Fatigue was also higher among chaplains who were divorced, and it increased with the number of hours per week the chaplains spent working with trauma victims or their families (r = .25, p<.05). Hierarchical multiple regression was performed to determine the influence of six professional and five personal variables on each of the three dependent variables. Four professional variables accounted for 19.5% of the variation and three personal variables accounted for 20.3% of the variation in Compassion Fatigue. Attempts to predict Burnout and Compassion Satisfaction were far less successful. Burnout was predicted by only two variables (i.e. age and years as a Rabbi), which accounted for just 18.4% of the variance in Burnout scores. Age was the only variable found to have a significant effect on Compassion Satisfaction, and its effect was positive. The implications of the findings are discussed.]
III. The Grosch & Olsen article noted above (in the section on Suggestions for the Use of the Article for Discussion in CPE) is part of an 8-article theme issue on burnout by the Journal of Clinical Psychology, covering the subject generally and with regard to such other specific groups as teachers, women lawyers, and people who work with child abuse and neglect. The full citation and abstract for the Grosch & Olsen article is as follows:
Grosch, W. N. and Olsen, D. C.
"Clergy burnout: an integrative approach." Journal of Clinical Psychology 56, no. 5 (May 2000): 619-632. [(Abstract:) Understanding how clergy, who begin their careers with high idealism, optimism, and compassion, burn out is difficult. One body of research suggests that clergy, among others, burn out because of the systems in which they work. From this perspective, burnout is the result of external systemic factors such as bureaucracy, poor administrative support, and difficult work conditions. The other body of research suggests that burnout is the result of intrapersonal factors such as high idealism, Type-A personality, narcissism, and perfectionism. It is our position that these two bodies of research are compatible, and that by integrating the Self psychology of Kohut with the general systems theory of Bowen, it becomes easier to understand burnout. Further, by integrating these two theories, principles for treatment become clearer.]
IV. The subject of burnout among chaplains is only a subset of the literature on burnout among clergy. In addition to the article by Grosch & Olsen cited directly above, the following recent studies may allow a foothold in that larger stream of literature.
Doolittle, B. R. "The impact of behaviors upon burnout among parish-based clergy." Journal of Religion & Health 49, no. 1 (March 2010): 88-95. [(Abstract:) Burnout has an important impact upon the professional satisfaction of clergy. Identifying protective behaviors that may prevent against burnout is important for the long-term emotional health of individual clergy as well as the wider church. This research reports findings among 358 parish-based clergy that identifies the prevalence of burnout and correlates this data with demographic risk factors and protective behaviors. Clergy who met criteria for burnout were younger, identified themselves as being depressed and unsatisfied with their spiritual life, and have endured a traumatic church placement. This research also suggests that having a variety of interests and activities outside of one's vocation may protect against burnout. In particular, behaviors that enhance relationships-such as seeking mentors and attending retreats-as well as pursuing outside activities-such as regular exercise and scholarly reading-protect against burnout. Further implications for the wider church are discussed.]
Francis, L. J., Hills, P. and Kaldor, P.
"The Oswald Clergy Burnout Scale: Reliability, Factor Structure and Preliminary Application Among Australian Clergy." Pastoral Psychology 57, nos. 5-6 (January 2009): 243-252. [(Abstract:) This study assesses the Oswald Clergy Burnout Scale (OCBI), the psychometric properties of which have not been previously described. Analysis of responses from a large number (N=3,012) of ministers in charge of Australian congregations showed that the scale's internal reliability was satisfactory, and that the scale could be represented by two factors, identified, respectively, as the personal and social aspects of burnout. This structure was supported by confirmatory factor analysis. Several demographic and job-related variables that might relate to burnout were regressed on the total, personal and social factor scores. Age is the predominant (negative) predictor of burnout as measured by the total scale and the personal factor scores. All variables predict burnout as measured by the social factor. However, in all models, the predictor variables account for no more than 5% of the total variance. These findings suggest that demographic factors and working conditions are poor predictors of burnout among clergy.]