Community Ment Health J (2014) 50:25–30 DOI 10.1007/s10597-013-9679-2
ORIGINAL PAPER
Dialectical Behavior Therapy Training to Reduce Clinical Burnout in a Public Behavioral Health System Adam Carmel • Alan E. Fruzzetti • Monica L. Rose
Received: 1 March 2013 / Accepted: 3 December 2013 / Published online: 18 December 2013 Ó Springer Science+Business Media New York 2013
Abstract There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to
A. Carmel (&) Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, Seattle, WA 98104, USA e-mail: [email protected] A. E. Fruzzetti Department of Psychology, University of Nevada, Reno, NV 89557, USA e-mail: [email protected] M. L. Rose Community Programs, San Francisco Department of Public Health, 1380 Howard St., San Francisco, CA 94103, USA e-mail: [email protected]
clients with BPD in order to enhance the quality of patient care. Keywords Dialectical behavior therapy Dissemination Community mental health
Introduction Borderline personality disorder (BPD) is considered to be one of the most crippling and frequently lethal of all psychiatric illnesses with a prevalence of about 2 % of the general population, 10 % of psychiatric outpatients, and 20 % of psychiatric inpatients (Lieb et al. 2004). The behavioral pattern most associated with BPD is chronic non-suicidal self-injury and suicidal behaviors, including frequents suicide attempts (Pompili et al. 2005). Rates of non-suicidal self-injury among individuals diagnosed with BPD range from 69 to 80 %, (Clarkin et al. 1983; Cowdry et al. 1985; Grove and Tellegen 1991; Gunderson 1984). The suicide rate is 5–10 %, and doubles when only those with a previous history of suicide attempts and/or selfinjuries are included (Frances et al. 1986; Linehan et al. 2000b; Stone 1993). Patients with BPD often have a high demand for treatment coupled with a poor response to standard outpatient treatments, thus leading to a high rate of utilization of services and financial burden among health systems that provide care. Many patients with BPD are among the highest utilizers of services within public sector settings (Bender et al. 2001; Linehan and Heard 1999). These individuals are often found to be high utilizers of acute psychiatric services, including inpatient admissions, crisis and emergency services (Bateman and Fonagy 2008; Comtois et al. 2007; Zanarini et al. 2004), and previous
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studies suggest that they consume up to 40 % of mental health services provided in a given setting even on an outpatient basis (Dimeff and Linehan 2001). Considerable burden is also placed on the clinicians providing treatment to patients with BPD in addition to the financial burdens associated with the high utilization of services. Clinicians widely agree that clients who meet criteria for BPD are challenging and difficult to treat and this in turn has led to a highly stigmatized disorder resulting in negative attitudes, trepidation, and concern among clinicians providing treatment (Linehan et al. 2000a). Clinicians treating clients with BPD are often overwhelmed by the amount of suffering of their patients and often develop a sense of hopelessness themselves about providing treatment to individuals with BPD (Hellman et al. 1986; Linehan et al. 2000a). These factors, taken together with the financial stressors unique to public sector mental health, have created an environment of pervasive hopelessness that is common among clinicians (Sorgaard et al. 2007) and often expands beyond individual clinicians to the larger public mental health system. Clinical burnout is defined as a prolonged response to chronic emotional and interpersonal stressors on the job and resulting in exhaustion, cynicism and inefficacy (Maslach and Jackson 1986). Schaufeli and Greenglass defined burnout as ‘‘a state of physical, emotional and mental exhaustion that results from long-term involvement in work situations that are emotionally demanding’’ (Schaufeli and Greenglass 2001). Exhaustion refers to depletion of energy and motivation in the performance of work tasks, including an increased need for rest, a state of physical fatigue, feelings of emptiness and the experience of being mentally, physically and emotionally drained from the demands of work (Demerouti et al. 2002; Knudsen 2006). Research has determined that clinicians working within a community behavioral healthcare system are more likely to encounter higher levels of clinical burnout due to high work demands and limited resources (Daub 2005; Gibson 2009; Onyett et al. 1997). Clinicians will often refuse to treat patients with BPD due to the risks associated with developing burnout (Linehan et al. 2000a). Clinicians that do provide treatment are likely to become emotionally exhausted, to depersonalize their clients, and to have diminished personal accomplishment in response to working with difficult-totreat clients (Linehan et al. 2000a). There are few published studies that have identified the pattern of burnout among clinicians treating individuals with BPD, particularly in community-based settings where resources are limited and demands are excessive (Soeteman et al. 2011). Additional research is needed to identify the rate of clinical burnout and strategies to decrease burnout in order to increase the capacity of providers to work with difficult-to-treat
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patients, particularly in community-based settings (Webster and Hackett 1999). Five psychotherapies have shown empirical support in the treatment of BPD, however dialectical behavior therapy (DBT) has been most studied and is the most widely disseminated. Other treatments that have empirical support include Mentalization-based treatment, which has shown decreases in suicidal and non-suicidal self-injury acts, inpatient days, depressive symptoms, and increases in social and interpersonal functioning (Bateman and Fonagy 2009). Schema-focused therapy and transference-focused psychotherapy also have shown empirically support (Giesen-Bloo et al. 2006) but are less available. Dialectical behavior therapy is the dominant evidence based treatment for BPD across the US and internationally. DBT has been shown to be effective at reducing suicidal behavior, psychiatric hospitalizations, ER visits, and other key outcomes in 10 randomized clinical trials (Koons et al. 2001; Linehan et al. 1991; Linehan et al. 2006; Linehan et al. 2002; Lynch et al. 2003a, b; Telch et al. 2001; Verheul et al. 2003). The dissemination of DBT has led to an effective treatment option for a vulnerable client population, and has created a sense of relief among clients, clinicians, and stakeholders in public health systems (Lynch et al. 2007). A number of studies have found increased clinician satisfaction with DBT compared to usual care (Barley et al. 1993; Kalmar et al. 2008; McCann and Ball 1998). The possible reasons for these improvements in clinician satisfaction include the specific targeting and strategies DBT provides in crisis and other highly stressful interactions, an emphasis on DBT clinicians practicing the core DBT skills of distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness, as well as the structure and support provided by the weekly consultation group which explicitly focuses on adherence to the treatment strategies most likely to be effective and maintaining clinician motivation and hope (Dimeff and Linehan 2001; Linehan 1993). There has been one published pre and post study examining the role of DBT in reducing burnout among clinicians providing treatment to clients with BPD (Perseius et al. 2007). This mixed method study was conducted in a health system in Sweden and included 22 clinicians from various disciplines that received a course of DBT training while providing treatment to patients that engaged in selfinjurious behaviors. There were no significant changes in pre and post measures of clinical burnout after the clinicians received training, yet qualitative analyses revealed that while DBT was viewed as stressful based on the learning demands, receiving training decreased the experience of stress associated with providing treatment. This information taken together with anecdotal data across multiple DBT trainings suggest that DBT shows promise in
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reducing burnout among community-based clinicians. Possible reasons for this include an emphasis in DBT on clinicians practicing core DBT skills of distress tolerance, mindfulness, and interpersonal effectiveness, as well as the support of a DBT case consultation group which functions to address the challenge of remaining on therapeutic tasks and maintaining motivation and hope (Linehan 1993). However, additional research is needed to determine the specific predictors of burnout and whether receiving training and practice in the delivery of evidence-based care results in decreased levels of burnout among clinicians. There is a particular need for training and implementation research within public health systems where clinicians are more likely to experience higher levels of clinical burnout (Webster and Hackett 1999). The goal of the present study is to determine whether receiving training in DBT will reduce burnout among therapists treating clients with BPD within a public behavioral health system.
Method Participants This study includes a sample of 34 mental health practitioners and substance abuse counselors within a large, urban public behavioral health system in Northern California. Participating clinicians provided a variety of services including methadone maintenance, substance abuse outpatient treatment, case management and/or outpatient mental health care. The clinicians in the sample were employed by agencies that had been selected to participate in a system-wide rollout of DBT with the goal of increasing the capacity of clinicians to effective treat clients with BPD. All participating clinicians were treating clients with BPD within seven community-based agencies taking part in the implementation project. Demographic data was collected from all 34 clinicians at the onset of DBT training. However, this information did not contain identifiers, so it was not possible to extract the demographic information for the clinicians who completed a follow-up assessment. The clinicians were 88 % female, and had a mean age of 39 years (SD = 9.62), a mean of 8.7 years (SD = 8.82) of clinical experience, and a mean of 1.2 years (SD = 3.16) of previous DBT experience. The highest educational levels of the clinicians included 94.1 % (N = 32) with a masters degree, 2.9 % (N = 1) with an associates degree, and 2.9 % (N = 1) with a doctoral degree. Pre and post scores of therapist burnout were obtained at baseline before the DBT training took place and again following a period of 13 months. Follow-up data was obtained for only 9 out of the 34 clinicians. Twenty-five of
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the clinicians did not complete post baseline data and because initial data collection did not contain identifiers, it was impossible follow up with specific participants to determine more accurately the reasons for attrition. However, it was thought that many participants were not able complete the post-baseline assessment because they were not in attendance in later trainings or were no longer employed in the same clinical role as when they attended the first training. Training A 10-day comprehensive DBT training (80 h) was provided over a period of 13 months by an expert DBT trainer. The training sessions occurred over a 13-month period, thus differing from the standard 10-day intensive model of DBT training. A variety of resources on maintaining successful adherence to DBT were made available to clinicians including an international DBT listserv, an online forum of video demonstrations of DBT interventions, phone consultation, and feedback on recorded sessions. The content of all trainings included time for case consultation and questions around team building in addition to the didactic components. The first training offered an introduction to DBT, and included background of the biosocial theory and an overview of the research supporting the efficacy of DBT. A three-day training followed a month later, and focused on program development and intensive team building. At 4 months post baseline, a two-day training was presented on DBT skills, problem assessment, skills coaching and DBT consultation team building. An advanced training in DBT followed 13 months after the initial training focusing on review of previous materials and case consultation. Measures An assessment of burnout was conducted using the Copenhagen Burnout Inventory (CBI). Participants were administered an assessment of burnout prior to receiving DBT training, and another assessment 13 months later, at which time the participants had received ten training sessions in DBT. The CBI is a measure with three sub-dimensions of personal burnout, work-related burnout, and client-related burnout (Kristensen et al. 2005) and has been found to have high internal reliability (a = .85-.87). Respondents indicate the degree of exhaustion and fatigue that is experienced overall, and more specifically in terms of how exhaustion and fatigue are attributed to the workplace and to work with clients specifically. While the Maslach Burnout Inventory (MBI; (Maslach and Jackson 1986) is the instrument most commonly used
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to measure burnout, we chose to use the CBI to offer a more thorough representation of clinical burnout. The MBI captures three dimensions of clinical burnout of emotional exhaustion, depersonalization, and reduced personal accomplishment, and measures these components of burnout independently. While the three dimensions often do occur simultaneously, the CBI offered a more thorough assessment of burnout my measuring how these concepts happen concurrently (Kristensen et al. 2005). The standardization sample of the CBI included 1,914 human service professionals in Denmark (Kristensen et al. 2005). Mean scores on clinical burnout were compared between the standardization sample of the CBI and the current study, and there was no significant difference between the two groups.
Results A Wilcoxon Signed Ranks Test was conducted using a matched sample of nine clinicians. There was a significant difference on pre-and-post mean ranked scores on the CBI (p \ .05, N = 9). An effect size of .76 was obtained (Cohen’s d = .76), indicating a substantial effect between the two groups, given the small number of participants included in this analysis. The Z-score of -2.199 indicates a decrease in pre-to-post in values for the mean ranks. The nine clinicians in the sample had significantly lower pre and post scores of burnout after attending a DBT training and practicing DBT within a 13 month period following the initial training (Table 1).
Discussion This study included a sample of nine clinicians showing a significant decrease in mean ranked scores of burnout after attending a series of DBT trainings over a period of 13 months. The findings suggest that DBT training holds promise as a way to reduce exhaustion and fatigue associated with burnout. Possible reasons for this include the specific targeting and strategies DBT provides in crisis and
Table 1 Pre-post comparisons of burnout scores among clinicians receiving training in DBT
CBI scores * p \ .05
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Pre-DBT training
?13 months
M
SD
M
SD
702.5
308.77
594.44
309.68
Effect size
p Value t (8)
.76
.028*
other highly stressful interactions, an emphasis on DBT clinicians practicing the core DBT skills of distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness, as well as the structure and support provided by the weekly consultation group which explicitly focuses on adherence to the treatment strategies most likely to be effective and maintaining clinician motivation and hope (Dimeff and Linehan 2001). There were several limitations to the study including the absence of a control group and a small sample size. There were other threats to internal validity associated with history based on events that occurred within the health system that may have influenced the sample’s scores of burnout. For example, many organizations within the health systems experienced financial cutbacks that resulted in several of the clinical teams losing many members of their clinical staff. For example, one team participating in the roll-out of DBT reported a loss of 60 % of their DBT clinicians due to either layoffs or to changing job responsibilities. Exhaustion and fatigue are likely to become more pronounced based on these types of organizational changes. Given the limitations on internal validity, there are no clear indications that the effects on burnout were caused by attending DBT training. However, these findings are consistent with previous studies and anecdotal evidence indicating that the DBT consultation team has the potential to reduce burnout among its members. Dismantling studies on DBT are needed to determine what components of the model lead to specific effects such as the decrease of burnout or the increase of motivation. The sample included DBT clinicians who in many cases performed clinical responsibilities outside of DBT, yet there was no data collected on the breakdown of clinical activities to determine the extent of how DBT was used compared to other treatments. For example, if providing DBT to clients with BPD was a minor component of a clinician’s job, then it is possible that the effects of the training would have a minor impact on clinical performance as well as on exhaustion and fatigue compared to a clinician delivering DBT on a full-time basis. External validity was maximized given that community-based clinicians often balance many different treatment modalities while treating patients with a range of functioning and needs. Future evaluations of EBP training should consider a more rigorous research design and controlling for the effects of other treatments provided and trainings attended. Health systems all around the world have gone to great time and expense to provide effective treatment of BPD and many health systems have rolled out DBT as a way to decrease the financial burdens associated with care. The pervasive sense of hopelessness among clinicians providing treatment to individuals with BPD suggests that burnout is a serious problem that impedes the delivery of evidence-based care, yet there is limited research to
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understand the specific aspects of clinical care that are associated with increased burnout. Additional research is needed to determine whether models of EBP training can improve the capacity of clinicians to treat patients, particularly for costly, vulnerable, and difficult-to-treat clinical populations such as BPD. Many systems will be unable to create improvements in the quality of patient health or well-being if burnout among clinicians continues to be overlooked. In order to enhance the quality of treatment among patients with BPD, it recommended that clinician burnout be included as a variable within DBT effectiveness and efficacy studies, and that pre and post differences on burnout be more widely disseminated in the scientific literature.
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29 Giesen-Bloo, J., van Dyck, R., Spinhoven, P., et al. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649–658. Grove, W. M., & Tellegen, A. (1991). Problems in the classification of personality disorders. Journal of Personality Disorders, 5, 31–41. Gunderson, J. G. (1984). Borderline personality disorder. Washington, DC: American Psychiatric Press. Hellman, I. D., Morrison, T. L., & Abramowitz, S. I. (1986). The stresses of psychotherapeutic work: A replication and extension. Journal of Clinical Psychology, 42(1), 197–205. Kalmar, S., Szanto, K., Rihmer, Z., Mazumdar, S., Harrison, K., & Mann, J. J. (2008). Antidepressant prescription and suicide rates: Effect of age and gender. Suicide and Life-Threatening Behavior, 38(4), 363–374. Knudsen, H. K. (2006). Counselor emotional exhaustion and turnover in therapeutic communities. Journal of Substance Abuse Treatment, 31(2), 173–180. Koons, C. R., Robins, C. J., Lindsey Tweed, J., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., et al. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371–390. Kristensen, T. G., Hannerz, H., Hogh, A., & Borg, V. (2005). The Copenhagen Psychosocial Questionnaire: A tool for the assessment and improvement of the psychosocial work environment. The Scandanavian Journal of Work and Environment Health, 31(6), 438–449. Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. Lancet, 364, 453–461. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060–1064. Linehan, M. M., Cochran, B. N., Mar, C. M., Levensky, E. R., & Comtois, K. A. (2000a). Therapeutic burnout among borderline disordered clients and their therapists: Development and evaluation of two adaptations of the Maslach Burnout Inventory. Cognitive and Behavioral Practice, 7, 329–337. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67, 13–26. Linehan, M. M., & Heard, H. L. (1999). Borderline personality disorder: Costs, course, and treatment outcomes. The CostEffectiveness of Psychotherapy: A Guide for Practitioners, Researchers and Policy-Makers. New York: Oxford Press. Linehan, M. M., Rizvi, S. L., Welch, S. S., & Page, B. (2000b). Psychiatric aspects of suicidal beahviour: Personality disorders. In K. Hawton (Ed.), International handbook of suicide and attempted suicide (pp. 147–178). Sussex, England: Wiley. Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003a). Dialectical behavioral therapy for depressed older adults. A randomized pilot study. American Journal of Geriatric Psychiatry, 11, 33–45.
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30 Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003b). Dialectical behavioral therapy for depressed older adults. A randomized pilot study. American Journal of Geriatric Psychiatry, 11, 33–45. Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007). Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181–205. Maslach, C., & Jackson, S. E. (1986). Maslach burnout inventory manual (2nd ed.). Palo Alto, CA: Consulting Psychologists Press. McCann, R., & Ball, E. (1998). The effectiveness of Dialectical Behavior Therapy in reducing burnout among forensic staff in acceptance and change: Applying dialectical behavior therapy in forensic and prison settings. Paper presented at the 32nd annual convention of the Association for the Advancement of Behavioral Therapy. Onyett, S., Pillinger, T., & Muijen, M. (1997). Job satisfaction and burnout among members of community mental health teams. Journal of Mental Health, 6(1), 55–66. Perseius, K. I., Kaver, A., Ekdahl, S., Asberg, M., & Samuelsson, M. (2007). Stress and burnout in psychiatric professionals when starting to use dialectical behavioural therapy in the work with young self-harming women showing borderline personality symptoms. Journal of Psychiatric and Mental Health Nursing, 14, 635–643. Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: A meta-analysis. Nordic Journal of Psychiatry, 59, 319–324. Schaufeli, W. B., & Greenglass, E. R. (2001). Introduction to special issue on burnout and health. Psychology and Health, 16(5), 501–510.
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Community Ment Health J (2014) 50:25–30 Soeteman, D. I., Busschback, J. J., Verheul, R., Hoomans, T., & Kim, J. J. (2011). Cost-effective psychotherapy for personality disorders in The Netherlands: The value of further research and active implementation. Value in Health, 14, 229–239. Sorgaard, K. W., Ryan, P., Hill, R., & Dawson, I. (2007). Sources of stress and burnout in acute psychiatric care: Inpatient vs. community staff. Social Psychiatry and Psychiatric Epidemiology, 42, 794–802. Stone, M. H. (1993). Long-term outcome in personality disorders. British Journal of Psychiatry, 162, 299–313. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavioral therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061–1065. Verheul, R., van den Bosch, L., Louise, M. C., Koeter, M. W., de Ridder, M. A. J., Stijnen, T., et al. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. British Journal of Psychiatry, 182, 135–140. Webster, L., & Hackett, R. K. (1999). Burnout and leadership in community mental health systems. Administration and Policy in Mental Health, 26(6), 387–399. Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2004). Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65(1), 28–36.
ORIGINAL PAPER
Dialectical Behavior Therapy Training to Reduce Clinical Burnout in a Public Behavioral Health System Adam Carmel • Alan E. Fruzzetti • Monica L. Rose
Received: 1 March 2013 / Accepted: 3 December 2013 / Published online: 18 December 2013 Ó Springer Science+Business Media New York 2013
Abstract There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to
A. Carmel (&) Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, Seattle, WA 98104, USA e-mail: [email protected] A. E. Fruzzetti Department of Psychology, University of Nevada, Reno, NV 89557, USA e-mail: [email protected] M. L. Rose Community Programs, San Francisco Department of Public Health, 1380 Howard St., San Francisco, CA 94103, USA e-mail: [email protected]
clients with BPD in order to enhance the quality of patient care. Keywords Dialectical behavior therapy Dissemination Community mental health
Introduction Borderline personality disorder (BPD) is considered to be one of the most crippling and frequently lethal of all psychiatric illnesses with a prevalence of about 2 % of the general population, 10 % of psychiatric outpatients, and 20 % of psychiatric inpatients (Lieb et al. 2004). The behavioral pattern most associated with BPD is chronic non-suicidal self-injury and suicidal behaviors, including frequents suicide attempts (Pompili et al. 2005). Rates of non-suicidal self-injury among individuals diagnosed with BPD range from 69 to 80 %, (Clarkin et al. 1983; Cowdry et al. 1985; Grove and Tellegen 1991; Gunderson 1984). The suicide rate is 5–10 %, and doubles when only those with a previous history of suicide attempts and/or selfinjuries are included (Frances et al. 1986; Linehan et al. 2000b; Stone 1993). Patients with BPD often have a high demand for treatment coupled with a poor response to standard outpatient treatments, thus leading to a high rate of utilization of services and financial burden among health systems that provide care. Many patients with BPD are among the highest utilizers of services within public sector settings (Bender et al. 2001; Linehan and Heard 1999). These individuals are often found to be high utilizers of acute psychiatric services, including inpatient admissions, crisis and emergency services (Bateman and Fonagy 2008; Comtois et al. 2007; Zanarini et al. 2004), and previous
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studies suggest that they consume up to 40 % of mental health services provided in a given setting even on an outpatient basis (Dimeff and Linehan 2001). Considerable burden is also placed on the clinicians providing treatment to patients with BPD in addition to the financial burdens associated with the high utilization of services. Clinicians widely agree that clients who meet criteria for BPD are challenging and difficult to treat and this in turn has led to a highly stigmatized disorder resulting in negative attitudes, trepidation, and concern among clinicians providing treatment (Linehan et al. 2000a). Clinicians treating clients with BPD are often overwhelmed by the amount of suffering of their patients and often develop a sense of hopelessness themselves about providing treatment to individuals with BPD (Hellman et al. 1986; Linehan et al. 2000a). These factors, taken together with the financial stressors unique to public sector mental health, have created an environment of pervasive hopelessness that is common among clinicians (Sorgaard et al. 2007) and often expands beyond individual clinicians to the larger public mental health system. Clinical burnout is defined as a prolonged response to chronic emotional and interpersonal stressors on the job and resulting in exhaustion, cynicism and inefficacy (Maslach and Jackson 1986). Schaufeli and Greenglass defined burnout as ‘‘a state of physical, emotional and mental exhaustion that results from long-term involvement in work situations that are emotionally demanding’’ (Schaufeli and Greenglass 2001). Exhaustion refers to depletion of energy and motivation in the performance of work tasks, including an increased need for rest, a state of physical fatigue, feelings of emptiness and the experience of being mentally, physically and emotionally drained from the demands of work (Demerouti et al. 2002; Knudsen 2006). Research has determined that clinicians working within a community behavioral healthcare system are more likely to encounter higher levels of clinical burnout due to high work demands and limited resources (Daub 2005; Gibson 2009; Onyett et al. 1997). Clinicians will often refuse to treat patients with BPD due to the risks associated with developing burnout (Linehan et al. 2000a). Clinicians that do provide treatment are likely to become emotionally exhausted, to depersonalize their clients, and to have diminished personal accomplishment in response to working with difficult-totreat clients (Linehan et al. 2000a). There are few published studies that have identified the pattern of burnout among clinicians treating individuals with BPD, particularly in community-based settings where resources are limited and demands are excessive (Soeteman et al. 2011). Additional research is needed to identify the rate of clinical burnout and strategies to decrease burnout in order to increase the capacity of providers to work with difficult-to-treat
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patients, particularly in community-based settings (Webster and Hackett 1999). Five psychotherapies have shown empirical support in the treatment of BPD, however dialectical behavior therapy (DBT) has been most studied and is the most widely disseminated. Other treatments that have empirical support include Mentalization-based treatment, which has shown decreases in suicidal and non-suicidal self-injury acts, inpatient days, depressive symptoms, and increases in social and interpersonal functioning (Bateman and Fonagy 2009). Schema-focused therapy and transference-focused psychotherapy also have shown empirically support (Giesen-Bloo et al. 2006) but are less available. Dialectical behavior therapy is the dominant evidence based treatment for BPD across the US and internationally. DBT has been shown to be effective at reducing suicidal behavior, psychiatric hospitalizations, ER visits, and other key outcomes in 10 randomized clinical trials (Koons et al. 2001; Linehan et al. 1991; Linehan et al. 2006; Linehan et al. 2002; Lynch et al. 2003a, b; Telch et al. 2001; Verheul et al. 2003). The dissemination of DBT has led to an effective treatment option for a vulnerable client population, and has created a sense of relief among clients, clinicians, and stakeholders in public health systems (Lynch et al. 2007). A number of studies have found increased clinician satisfaction with DBT compared to usual care (Barley et al. 1993; Kalmar et al. 2008; McCann and Ball 1998). The possible reasons for these improvements in clinician satisfaction include the specific targeting and strategies DBT provides in crisis and other highly stressful interactions, an emphasis on DBT clinicians practicing the core DBT skills of distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness, as well as the structure and support provided by the weekly consultation group which explicitly focuses on adherence to the treatment strategies most likely to be effective and maintaining clinician motivation and hope (Dimeff and Linehan 2001; Linehan 1993). There has been one published pre and post study examining the role of DBT in reducing burnout among clinicians providing treatment to clients with BPD (Perseius et al. 2007). This mixed method study was conducted in a health system in Sweden and included 22 clinicians from various disciplines that received a course of DBT training while providing treatment to patients that engaged in selfinjurious behaviors. There were no significant changes in pre and post measures of clinical burnout after the clinicians received training, yet qualitative analyses revealed that while DBT was viewed as stressful based on the learning demands, receiving training decreased the experience of stress associated with providing treatment. This information taken together with anecdotal data across multiple DBT trainings suggest that DBT shows promise in
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reducing burnout among community-based clinicians. Possible reasons for this include an emphasis in DBT on clinicians practicing core DBT skills of distress tolerance, mindfulness, and interpersonal effectiveness, as well as the support of a DBT case consultation group which functions to address the challenge of remaining on therapeutic tasks and maintaining motivation and hope (Linehan 1993). However, additional research is needed to determine the specific predictors of burnout and whether receiving training and practice in the delivery of evidence-based care results in decreased levels of burnout among clinicians. There is a particular need for training and implementation research within public health systems where clinicians are more likely to experience higher levels of clinical burnout (Webster and Hackett 1999). The goal of the present study is to determine whether receiving training in DBT will reduce burnout among therapists treating clients with BPD within a public behavioral health system.
Method Participants This study includes a sample of 34 mental health practitioners and substance abuse counselors within a large, urban public behavioral health system in Northern California. Participating clinicians provided a variety of services including methadone maintenance, substance abuse outpatient treatment, case management and/or outpatient mental health care. The clinicians in the sample were employed by agencies that had been selected to participate in a system-wide rollout of DBT with the goal of increasing the capacity of clinicians to effective treat clients with BPD. All participating clinicians were treating clients with BPD within seven community-based agencies taking part in the implementation project. Demographic data was collected from all 34 clinicians at the onset of DBT training. However, this information did not contain identifiers, so it was not possible to extract the demographic information for the clinicians who completed a follow-up assessment. The clinicians were 88 % female, and had a mean age of 39 years (SD = 9.62), a mean of 8.7 years (SD = 8.82) of clinical experience, and a mean of 1.2 years (SD = 3.16) of previous DBT experience. The highest educational levels of the clinicians included 94.1 % (N = 32) with a masters degree, 2.9 % (N = 1) with an associates degree, and 2.9 % (N = 1) with a doctoral degree. Pre and post scores of therapist burnout were obtained at baseline before the DBT training took place and again following a period of 13 months. Follow-up data was obtained for only 9 out of the 34 clinicians. Twenty-five of
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the clinicians did not complete post baseline data and because initial data collection did not contain identifiers, it was impossible follow up with specific participants to determine more accurately the reasons for attrition. However, it was thought that many participants were not able complete the post-baseline assessment because they were not in attendance in later trainings or were no longer employed in the same clinical role as when they attended the first training. Training A 10-day comprehensive DBT training (80 h) was provided over a period of 13 months by an expert DBT trainer. The training sessions occurred over a 13-month period, thus differing from the standard 10-day intensive model of DBT training. A variety of resources on maintaining successful adherence to DBT were made available to clinicians including an international DBT listserv, an online forum of video demonstrations of DBT interventions, phone consultation, and feedback on recorded sessions. The content of all trainings included time for case consultation and questions around team building in addition to the didactic components. The first training offered an introduction to DBT, and included background of the biosocial theory and an overview of the research supporting the efficacy of DBT. A three-day training followed a month later, and focused on program development and intensive team building. At 4 months post baseline, a two-day training was presented on DBT skills, problem assessment, skills coaching and DBT consultation team building. An advanced training in DBT followed 13 months after the initial training focusing on review of previous materials and case consultation. Measures An assessment of burnout was conducted using the Copenhagen Burnout Inventory (CBI). Participants were administered an assessment of burnout prior to receiving DBT training, and another assessment 13 months later, at which time the participants had received ten training sessions in DBT. The CBI is a measure with three sub-dimensions of personal burnout, work-related burnout, and client-related burnout (Kristensen et al. 2005) and has been found to have high internal reliability (a = .85-.87). Respondents indicate the degree of exhaustion and fatigue that is experienced overall, and more specifically in terms of how exhaustion and fatigue are attributed to the workplace and to work with clients specifically. While the Maslach Burnout Inventory (MBI; (Maslach and Jackson 1986) is the instrument most commonly used
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to measure burnout, we chose to use the CBI to offer a more thorough representation of clinical burnout. The MBI captures three dimensions of clinical burnout of emotional exhaustion, depersonalization, and reduced personal accomplishment, and measures these components of burnout independently. While the three dimensions often do occur simultaneously, the CBI offered a more thorough assessment of burnout my measuring how these concepts happen concurrently (Kristensen et al. 2005). The standardization sample of the CBI included 1,914 human service professionals in Denmark (Kristensen et al. 2005). Mean scores on clinical burnout were compared between the standardization sample of the CBI and the current study, and there was no significant difference between the two groups.
Results A Wilcoxon Signed Ranks Test was conducted using a matched sample of nine clinicians. There was a significant difference on pre-and-post mean ranked scores on the CBI (p \ .05, N = 9). An effect size of .76 was obtained (Cohen’s d = .76), indicating a substantial effect between the two groups, given the small number of participants included in this analysis. The Z-score of -2.199 indicates a decrease in pre-to-post in values for the mean ranks. The nine clinicians in the sample had significantly lower pre and post scores of burnout after attending a DBT training and practicing DBT within a 13 month period following the initial training (Table 1).
Discussion This study included a sample of nine clinicians showing a significant decrease in mean ranked scores of burnout after attending a series of DBT trainings over a period of 13 months. The findings suggest that DBT training holds promise as a way to reduce exhaustion and fatigue associated with burnout. Possible reasons for this include the specific targeting and strategies DBT provides in crisis and
Table 1 Pre-post comparisons of burnout scores among clinicians receiving training in DBT
CBI scores * p \ .05
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Pre-DBT training
?13 months
M
SD
M
SD
702.5
308.77
594.44
309.68
Effect size
p Value t (8)
.76
.028*
other highly stressful interactions, an emphasis on DBT clinicians practicing the core DBT skills of distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness, as well as the structure and support provided by the weekly consultation group which explicitly focuses on adherence to the treatment strategies most likely to be effective and maintaining clinician motivation and hope (Dimeff and Linehan 2001). There were several limitations to the study including the absence of a control group and a small sample size. There were other threats to internal validity associated with history based on events that occurred within the health system that may have influenced the sample’s scores of burnout. For example, many organizations within the health systems experienced financial cutbacks that resulted in several of the clinical teams losing many members of their clinical staff. For example, one team participating in the roll-out of DBT reported a loss of 60 % of their DBT clinicians due to either layoffs or to changing job responsibilities. Exhaustion and fatigue are likely to become more pronounced based on these types of organizational changes. Given the limitations on internal validity, there are no clear indications that the effects on burnout were caused by attending DBT training. However, these findings are consistent with previous studies and anecdotal evidence indicating that the DBT consultation team has the potential to reduce burnout among its members. Dismantling studies on DBT are needed to determine what components of the model lead to specific effects such as the decrease of burnout or the increase of motivation. The sample included DBT clinicians who in many cases performed clinical responsibilities outside of DBT, yet there was no data collected on the breakdown of clinical activities to determine the extent of how DBT was used compared to other treatments. For example, if providing DBT to clients with BPD was a minor component of a clinician’s job, then it is possible that the effects of the training would have a minor impact on clinical performance as well as on exhaustion and fatigue compared to a clinician delivering DBT on a full-time basis. External validity was maximized given that community-based clinicians often balance many different treatment modalities while treating patients with a range of functioning and needs. Future evaluations of EBP training should consider a more rigorous research design and controlling for the effects of other treatments provided and trainings attended. Health systems all around the world have gone to great time and expense to provide effective treatment of BPD and many health systems have rolled out DBT as a way to decrease the financial burdens associated with care. The pervasive sense of hopelessness among clinicians providing treatment to individuals with BPD suggests that burnout is a serious problem that impedes the delivery of evidence-based care, yet there is limited research to
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understand the specific aspects of clinical care that are associated with increased burnout. Additional research is needed to determine whether models of EBP training can improve the capacity of clinicians to treat patients, particularly for costly, vulnerable, and difficult-to-treat clinical populations such as BPD. Many systems will be unable to create improvements in the quality of patient health or well-being if burnout among clinicians continues to be overlooked. In order to enhance the quality of treatment among patients with BPD, it recommended that clinician burnout be included as a variable within DBT effectiveness and efficacy studies, and that pre and post differences on burnout be more widely disseminated in the scientific literature.
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