Chapter 15

Professional Burnout
Wilmar B. Schaufeli

University of Utrecht , Utrecht, The Netherlands and

Bram P. Buunk
University of Groningen, Groningen, The Netherlands

15.1 A BRIEF HISTORY OF THE BURNOUT CONCEPT

Burnout is a metaphor that is commonly used to describe a state or process of mental
exhaustion, similar to the smothering of a fire or the extinguishing of a candle. The
dictionary defines ‘to burn out’ as ‘to fail, wear out, or become exhausted by making
excessive demands on energy, strength, or resources’. Probably the earliest example in
which ‘to burn out’ is related to exhaustion comes from Shakespeare, who wrote in 1599
in The Passionate Pilgrim, ‘She burnt with loue, as straw with fire flameth. She burnt out
loue, as soon as straw out burneth’ (cited in Enzmann and Kleiber, 1989, p. 18). More
recently, but long before the ‘discovery’ of burnout in professional settings, people who
suffer from it have been portrayed in great detail, for instance, in Graham Greene’s 1960
novel A Burnt-Out Case, which tells the sad story of the world famous architect Querry, a
gloomy, spiritually tormented, cynical and disillusioned character. The most illustrious
example of burnout avant-la-lettre is the case study of a psychiatric nurse, Miss Jones,
published by Schwartz and Will (1953) in Psychiatry.

15.1.1 The 'Discovery' of Professional Burnout

Although the term ‘staff burnout’ was first mentioned by Bradley (1969) in an article
about probation officers running a community based treatment programme for

Handbook of Work and Health Psychology.

Edited by M.J. Schabracq, J.A.M. Winnubst and C.L. Cooper. © 1996 John Wiley & Sons Ltd.
juvenile delinquents, Herbert Freudenberger (1974) is generally considered to be the
founding father of the burnout syndrome. His influential paper on staff burnout set the
stage for the introduction of the concept. As an unpaid psychiatrist, Freudenberger was
employed in a New York Free Clinic for drug addicts that was staffed mainly by young,
idealistically motivated volunteers. Freudenberger observed that many of them
experienced a gradual energy depletion and loss of motivation and commitment, which
was accompanied by a wide array of mental and physical symptoms. To label this
particular state of exhaustion, which usually occurred about one year after the volunteers
312 W.M. SCHAUFELI AND B.P. BUUNK
started working in the clinic, Freudenberger chose a word that was being used casually to
refer to the effects of chronic drug abuse: burnout.
At about the same time, Christina Maslach (1976), a social psychologist, became
interested in the way in which people in the human services cope with emotional arousal
on the job. She noticed that the term ‘burnout’ was colloquially used by Californian
poverty lawyers to describe the process of gradual exhaustion, cynicism and loss of
commitment in their colleagues. Maslach and her co-workers decided to adopt this term
because it was easily recognized by the interviewees in their study among human services
professionals.

15.1.2 The Pioneer Phase

After the introduction of the concept by Freudenberger (1974,1975) and by Maslach and
her colleagues (Maslach, 1976; Pines and Maslach, 1978), burnout soon became a very
popular topic. Apparently, the appropriate name had been given to something that was
‘in the air’. The first publications on professional burnout appeared primarily in journals,
magazines and periodicals for a variety of professionals, including not only teachers,
social workers, nurses, physicians and managers, but also dentists, fire fighters and
librarians. The mass media eagerly picked up the burnout concept, and public interest in
this topic grew enormously, making burnout a buzz word in the late 1970s, and early
1980s. At the same time, a tremendous proliferation of workshops, training materials and
interventions took place. In a certain sense, burnout became big business.
Because in this so-called pioneer phase (Maslach and Schaufeli, 1993) it was mainly
practitioners and the general public who were interested in professional burnout, the
conceptual development was influenced by pragmatic rather than scholarly concerns.
This resulted in a blurred, all-encompassing meaning of burnout. Many authors stretched
the concept of burnout to encompass far more than it did originally, so that in the end it
ran the risk of hardly meaning anything at all. Furthermore, the early burnout literature
was descriptive and not empirical, and relied heavily on unsystematic observations.
Narrative papers mainly emphasized the importance of individual factors, such as
overcommitment, idealism and perfectionism. An early review indicated that only 5 of the
48 articles included empirical data that went beyond an occasional anecdote or personal
case history (Perlman and Hartman, 1982).
The image of burnout as a popular term used by journalists and practioners hampered
the serious scientific study of this phenomenon. This is nicely illustrated by the rejection of
the psychometric article that introduced the Maslach Burnout Inventory (MBI), which
was later to become the most widely used and best validated instrument to assess burnout.
The journal editor returned the manuscript with a short note saying that it had not even
been read ‘because we do not publish “pop” psychology’ (Maslach and Jackson, 1984, p.
139).

15.1.3 The Empirical Phase

Despite the fact that professional burnout initially was not viewed as a serious scientific
PROFESSIONAL BURNOUT 313
topic, empirical research on this phenomenon started to flourish from the beginning of
the 1980s. Kilpatrick (1989) counted 195 published research articles on burnout up to
1987. A major impulse came from the introduction of short and easy to administer self-
report questionnaires to assess burnout (cf. Schaufeli, Enzmann and Girault, 1993). In
particular, the popularity of the MBI grew rapidly, and with it the multidimensional
model of burnout that the inventory is supposed to measure (Maslach and Jackson, 1981,
1986). Academic interest was also stimulated by scholarly books that offered
comprehensive social psychological (Maslach, 1982a; Pines and Aronson, with Kafry,
1981) and organizational (Cherniss, 1980a,b; Golembiewski, Munzenrider and Stevenson,
1986) perspectives on burnout.
Maslach and Schaufeli (1993), distinguished five trends in the so-called empirical
phase, which started in the mid-1980s. The first of these was the almost universal use of a
limited set of standardized burnout questionnaires—especially the MBI—which highly
structured the field. Secondly, burnout started to attract attention in other countries
outside the USA, beginning with English speaking countries such as the UK and Canada,
but soon followed by countries from the European mainland (e.g. Germany, France,
Sweden, Spain, Poland, Italy and The Netherlands) and from Asia (e.g. Israel, Jordan,
China and Japan). The first cross-national studies appeared (for a review, see
Golembiewski, Scherb and Boudreau, 1993). Thirdly, most of the research continued to
be done within people-orientated, human services occupations. Only occasionally was
burnout extended to other populations or non-occupational areas such as sports or
political activism. According to a recent bibliography on burnout that included 2496
publications, 43% referred to the fields of health and social work, 32% to education, 9%
to administration and management, 4% to law enforcement and police, and 12 % to other
groups (e.g. students, married couples and priests) (Kleiber and Enzmann, 1990).
Fourthly, research tended to focus more on job and organizational factors than on
individual factors, which is consistent with most of the models developed in this area.
Finally, the methodological rigour of burnout research has improved over the years
(Kilpatrick, 1989). Two recent trends could be added to this list: (i) a growing number of
comprehensive conceptual approaches that have proposed to link burnout to other
psychological theories; and (ii) an increased interest in the development of burnout over
time (cf. Schaufeli, Maslach and Marek, 1993).
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15.2 DEFINITIONS OF BURNOUT
In most early writings burnout was ‘defined’ merely by summing up the symptoms (e.g.
Freudenberger, 1974, p. 160). Such ‘laundry lists’ are problematic because they are
inevitably selective and because they tend to ignore the dynamic aspect of the syndrome.
These drawbacks are avoided either by selecting the most characteristic core symptoms of
burnout, as is done in state definitions, or by describing the process of burnout, as is done
in process definitions. Of course, both types of definitions—of which only the most
important examples are presented—are not mutually exclusive. Even more so, in a certain
sense they are complementary, because state definitions describe the end state of the
burnout process.

15.2.1 State Definitions of Burnout

Probably the most frequently cited definition of burnout comes from Maslach and
Jackson (1986, p. 1):
Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal
accomplishment that can occur among individuals who do ‘people work’ of some kind.
Its popularity is due to the fact that the most widely used self-report questionnaire, the
MBI, includes the three dimensions that are mentioned in this definition. Emotional
exhaustion refers to the depletion or draining of emotional resources. Depersonalization
points to the development of negative, callous and cynical attitudes towards the recipients
of one’s services. The term ‘depersonalization’ may cause some confusion, since it is used
in a completely different sense in psychiatry to denote a person’s extreme alienation from
the self and the world. However, in the definition of Maslach and Jackson, the term refers
to an impersonal and dehumanized perception of recipients, rather than to an impersonal
view of the self. Finally, lack of personal accomplishment is the tendency to evaluate one’s
work with recipients negatively. Burned-out professionals believe that their objectives are
not achieved, which is accompanied by feelings of insufficiency and poor professional self-
esteem. Most importantly, Maslach and Jackson (1981, 1986) claim that burnout occurs
exclusively in occupational groups where professionals deal directly with recipients such
as students, pupils, clients, patients, consumers or delinquents. Hence, burnout is, in their
view, restricted to the helping professions, including health care, education and the
human services.
Pines and Aronson (1988) present a somewhat broader definition of burnout. Unlike
Maslach and Jackson (1986), these authors include physical symptoms as well, and do not
restrict burnout to the helping professions. They describe burnout as:
a state of physical, emotional, and mental exhaustion caused by long-term involvement
in situations that are emotionally demanding, (p. 9)
Physical exhaustion is characterized by low energy, chronic fatigue, weakness and a wide
variety of physical and psychosomatic complaints. Emotional exhaustion involves feelings
of helplessness, hopelessness and entrapment. Finally, mental exhaustion refers to the
development of negative attitudes towards one’s self, work and life itself. Since excessive
emotional demands are not restricted to the human services, burnout can, according to
Pines (1993), also occur in occupational settings such as managerial jobs, as well as in
PROFESSIONAL BURNOUT 315
such diverse settings as love and marriage, and political activism.
Finally, a less well-known but more precise definition of burnout has been proposed by
Brill (1984, p. 15):
Burnout is an expectationally mediated, job-related, dysphoric and dysfunctional state in
an individual without major psychopathology who has (1) functioned for a time at
adequate performance and affective levels in the same job situation and who (2) will not
recover to previous levels without outside help or environmental rearrangement.
Accordingly, distress from lay-off or economic hardship is not interpreted as burnout
since it is not expectionally mediated. Moreover, burnout can occur in every type of job
but not outside the occupational context. In addition, incompetent individuals are
excluded as well as those who suffer from mental illness. Finally, individuals who either
experience a temporary decrement in their performance or who are able to recover on
their own are not considered burned-out.
To summarize, although state definitions of burnout differ in scope, precision and
dimensionality of the syndrome, they seem to share five common elements:
1. Dysphoric symptoms, and most notably emotional exhaustion, are predominant.
2. The accent is on mental and behavioural symptoms, although atypical physical
symptoms are sometimes mentioned as well.
3. Burnout is generally considered to be work-related.
4. The symptoms are observed in ‘normal’ individuals.
5. Decreased effectiveness and work performance occur because of negative attitudes and
behaviours.

15.2.2 Burnout as a Dynamic Process

More than a decade ago, Cherniss (1980a, p. 5) was among the first to propose a
straightforward description of burnout as a process: ‘Burnout refers to a process in which
the professionals’ attitudes and behavior change in negative ways in response to job
strain’. More specifically:
The first stage involves an imbalance between resources and demands (stress). The
second stage is the immediate, short-term emotional tension, fatigue, and exhaustion
(strain). The third stage consists of a number of changes in attitude and behavior, such as
a tendency to treat clients in a detached and mechanical fashion, or a cynical
preoccupation with gratification of one’s own needs (defensive coping). (Cherniss,
1980b, p. 17)
Thus, Cherniss considered excessive job demands as the root cause of professional
burnout, fostered by a defensive coping strategy characterized by avoidance and
withdrawal.
Other process definitions have emphasized the gradual development of burnout. For
instance, Edelwich and Brodsky (1980) described burnout in the helping professions as a
process of increasing disillusionment, the ‘progressive loss of idealism, energy, and
purpose experienced by people in the helping professions as a result of conditions in their
work’ (p. 14). According to Etzion (1987), burnout is a slowly developing process that
starts without warning and evolves almost unrecognized up to a particular point.
Suddenly and unexpectedly, one feels exhausted and one is not able to relate this
devastating experience to any particular stressful event. Etzion suggested that:
316 W.M. SCHAUFELI AND B.P. BUUNK
continuous, barely recognizable, and for the most part denied, misfits between personal
and environmental characteristics are the source of a slow and hidden process of
psychological erosion. Unlike other stressful phenomena, the mini-stressors of misfit do
not cause alarm and are rarely subject to any coping efforts. Thus the process of erosion
can go on for a long time without being detected. (1987, pp. 16-17)

More recently, Hallsten (1993) presented a more complex framework for the process of
burning-out. He defined burnout as ‘a form of depression that results from the process of
burning out, which is a necessary cause of burnout’ (p. 99). Accordingly, it is not the
outcome (i.e. a particular depressive state) that is considered to be specific for burnout but
its aetiology: the process of burning out, which develops in several phases. Hallsten (1993)
assumed that the process of burning out occurs ‘when the enactment of an active, self-
definitorial role is threatened or disrupted with no alternative role at hand’ (p. 99).
To conclude, most process definitions of burnout maintain that burnout begins with
stress resulting from the discrepancy between, on the one hand, the individual’s
expectations and ideals, and, on the other, the harsh reality of everyday occupational life.
This stress may be consciously observed by the individual or it may remain unnoticed for
a long time. Gradually, the individual starts to feel emotionally strained, and begins to
change his or her attitudes towards the job and the people he or she works with, a process
that finally results in burnout. The way in which the individual copes with stress is in most
process definitions considered crucial for the development of burnout.

15.3 OLD WINE IN NEW BOTTLES?

Professional burnout has been equated with a myriad of terms, most of which are plagued
by the same sort of definitional ambiguity: tedium, stress, job dissatisfaction, depression,
alienation, low morale, anxiety, strain, tension, feeling ‘worn-out’, ‘nerves’, boredom,
chronic fatigue, poor mental health, personal crisis, professional melancholia and vital
exhaustion (cf. Maslach and Schaufeli, 1993). Thus, the distinctiveness of burnout from
other related and more familiar psychological constructs is an important issue. In
particular, questions have been raised about the extent to which burnout can be
distinguished from job stress and depression.
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15.3.1 Burnout and job Stress
Occupational stress occurs when job demands tax or exceed the person’s adaptive
resources (Lazarus and Folkman, 1984). Stress is a generic term that refers to the
temporary adaptation process that is accompanied by mental and physical symptoms. In
contrast, burnout can be considered as a final stage in a breakdown in adaptation that
results from the long-term imbalance of demands and resources, and thus from prolonged
job stress (Brill, 1984). A related conceptual distinction between burnout and stress is that
the former includes the development of negative attitudes and behaviours towards
recipients, the job and the organization, whereas job stress is not necessarily accompanied
by such attitudes and behaviours (Maslach, 1993). This assertion was empirically
supported by Schaufeli and Van Dierendonck (1993), who showed the discriminant
validity of burnout, as measured with the MBI (particularly depersonalization and
reduced personal accomplishment), and generic mental and physical symptoms of job
stress. Finally, it has been claimed that everybody can experience stress, while burnout
can only be experienced by those who entered their careers enthusiastically, with high
goals and expectations. For example, Pines (1993) has argued that individuals who expect
to derive a sense of significance from their work are susceptible to burnout. Those
without such expectations would experience job stress instead of burnout. Thus, burnout
is a specific type of job stress that is characterized by its chronic and multi-faceted nature.
Moreover, it includes the development of negative attitudes, and it occurs among initially
highly motivated individuals.

15.3.2 Burnout and Depression

According to F reudenberger (1983), burnout tends, at least initially, to be job-related and
situation-specific rather than pervasive. Instead, a ‘real’ depression generalizes across
situations and other spheres of life. In a similar vein, according to Warr (1987),
depression concerns context-free affective well-being, whereas burnout concerns job-
related affective well-being. Nevertheless, although burnout and depression are different
phenomena, they also overlap to a certain extent (e.g. Meier, 1984). Empirical research on
the discriminant validity of both concepts shows that the emotional exhaustion component
of burnout particularly is substantively related to depression. The relationships with the
other burnout components, depersonalization and personal accompalishment, are less
strong (Firth et al., 1986; Glass, McKnight and Valdimarsdottir, 1993; Leiter and Durup,
1994). The fact that depression is differently related to different components of burnout
underlines the validity of a multidimensional model of burnout.
To conclude, it seems that burnout is a separate phenomenon, and that researchers of
burnout are not just putting ‘old wine in new bottles’. Burnout is, more than depression,
a multidimensional phenomenon, but is at the same time, unlike depression, restricted to
the job setting. Moreover, burnout is different from job stress in several ways: it refers
more to a breakdown in adaptation as a result of prolonged job stress, it is characterized
by a multidimensional symptomatology, particularly specific attitudes, and it seems partly
the result of a high initial level of motivation.
318 W.M. SCHAUFELI AND B.P. BUUNK
15.4 MEASUREMENT
Many different instruments to assess professional burnout have been proposed (for a
review see Schaufeli, Enzmann and Girault, 1993). Most of these instruments are self-
report measures, particularly designed to assess the level of burnout in the human
services professions. Although all measures focus in one way or another on the
individual’s depletion of emotional resources as the core meaning of burnout, less
agreement exists about the number and the nature of the other burnout dimensions
involved.

15.4.1 Maslach Burnout Inventory

Despite the variety of burnout measures, two instruments are used most frequently. The
most popular instrument, the MBI (Maslach and Jackson, 1986), contains three scales:
emotional exhaustion, depersonalization and (reduced) personal accomplishment. The
psychometric quality of the MBI is encouraging, at least in human services samples: the
three scales are internally consistent and the three-factor structure has been confirmed in
various studies (Schaufeli, Enzmann and Girault, 1993). However, in other samples, the
depersonalization items (which pertain to co-workers instead of recipients) do not form a
coherent or meaningful factor (Evans and Fischer, 1993). The core symptom of burnout—
emotional exhaustion—is the most robust scale of the MBI, and is strongly related to
other burnout measures (convergent validity). Paradoxically, as noted before, it is also the
least specific scale, and cannot easily be distinguished from related concepts such as
depression (discriminant validity). Similar positive psychometric results have been
obtained with the French (Dion and Tessier, 1994), German (Bussing and Perrar, 1992;
Enzmann and Kleiber, 1989) and Dutch (Schaufeli and Van Dierendonck, 1993) versions
of the MBI. Moreover, the cross-national validity of the MBI in these three European
countries has been demonstrated (Enzmann, Schaufeli and Girault, 1994).

15.4.2 Burnout Measure

The second most widely employed burnout questionnaire is the Burnout Measure (BM)
(Pines and Aronson, 1988), originally denoted the Tedium Measure (Pines and Aronson,
with Kafry, 1981). In contrast to the MBI, the BM is also appropriate for measuring
burnout outside the human services professions. The BM is a valid and reliable
questionnaire, which assesses the person’s level of physical, emotional and mental
exhaustion (Schaufeli, Enzmann and Girault, 1993). Recently, the one- dimensionality of
the BM has been questioned by Enzmann and Kleiber (1989), who found three
dimensions in their German sample (demoralization, exhaustion and loss of motivation).
Their results have been confirmed in The Netherlands by Schaufeli and Van Dierendonck
(1993).

15.4.3 Levels of Burnout

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It must be emphasized that there are no clinically valid cut-off points available for the BM
and the MBI that allow differentiation between levels of burnout. The MBI test manual
only presents numerical cut-off points based on arbitrary statistical norms. The test
authors divided the normative sample into three equally sized groups of 33.3%, assuming
that the top, intermediate and bottom thirds of the samples would experience ‘high’,
‘average’ and ‘low’ levels of burnout, respectively (Maslach and Jackson, 1986, p. 3).
Although the test authors correctly warn that this classification should not be used for
diagnostic purposes, there is a strong tendency for some researchers to differentiate
burnout cases from non-cases (e.g. Ackerley et al., 1988; Firth et al., 1985). Clearly this is
an inappropriate approach, not only since the cut-off points are based on arbitrary
statistical norms, but also because they are computed from a composite convenience
sample that is not representative for the US human services. Recently, Schaufeli and Van
Dierendonck (1955) showed that, as expected, levels of burnout are significantly higher in
an outpatient sample compared to working samples. Moreover, levels of emotional
exhaustion, depersonalization and personal accomplishment were significantly higher in
the American normative MBI sample than in the Dutch normative sample. Thus, extreme
caution is required when cut-off points are used to classify subjects according to their
level of burnout: only nation-specific and clinically validated cut-off points should be
employed.

15.5 CORRELATES, SYMPTOMS AND CONSEQUENCES OF

BURNOUT
In the past decades, many personal and organizational factors have been found to be
related to burnout, and a large variety of burnout symptoms and consequences of burnout
has been described. Before discussing the empirical evidence on this issue, it must be
noted that although the quality of burnout research has increased over the years, most
studies of the past two decades lack methodological rigour. As noted by Kilpatrick (1989,
p. 42), ‘The “typical” burnout study may be described as a one-shot, paper-and-pencil
survey using a convenience sample to obtain individual self-report information’.
Therefore, the empirical results that are described below should be interpreted with some
caution. For reasons of clarity not all references are included; sometimes only the most
recent or methodologically most rigorous studies are mentioned (for more detailed
reviews see Burisch, 1989; Cordes and Dougherty, 1993; Kahili, 1988; Schaufeli, 1990,
Shirom, 1989).
320 W.M.SCHAUFELI AND B.P. BUUNK
15.5.1 Correlates of Burnout
Demographic Characteristics

Most studies do not systematically investigate demographic differences in burnout.

Nevertheless, burnout—at least in the USA—seems to occur most frequently among
young employees aged under 30 or 40, who have relatively little work experience (e.g.
Byrne, 1991). However, these results must be interpreted with some caution because of
selective dropout. It is quite likely that employees who are burned out have left—or had to
leave—their jobs, so that the remaining group of older and more experienced
employees—the ‘survivors’—is relatively healthy. This so-called ‘healthy worker effect’
has often been observed in studies on job stress (Karasek and Theorell,
1990) . Quite remarkably, in European countries, such as The Netherlands, burnout is
more prevalent in older age groups (Schaufeli and Van Dierendonck, 1994). Probably,
European employees are more reluctant to change jobs because cultural values and social
security systems restrict labour market mobility more than in the USA.
Initially, it was claimed that women report higher burnout levels than men (Etzion and
Pines, 1986). However, as Greenglass (1991) has pointed out, gender is often confounded
with occupational role and hierarchical position. For instance, compared to men, women
less frequently occupy supervisory roles in organizations and so they have less access to
job-related rewards such as high income, social status and autonomy. When these
confounding variables are taken into account, no significant gender differences in burnout
are observed, except for depersonalization. It is consistently found that males report
higher depersonalization scores than females, a finding that is in line with other gender
differences such as higher prevalence of aggression among males, and higher interest in
the nurturing role among females (Ogus, Greenglass and Burke, 1990).
Burnout is associated with higher levels of education (Maslach and Jackson,
1981) . This is quite remarkable since most stress-related problems seem more prevalent
among workers with low status and poor education (Fletcher, 1988). Finally, most studies
show that single people have an increased risk of burning-out compared to those living
with a partner (Maslach and Jackson, 1985). It is claimed that social support from the
partner might alleviate stress.

Job Characteristics

Some studies indicate that burnout is positively related to objective indicators of

workload, such as the number of pupils for classroom teachers (DePaepe, French and
Lavay, 1985), intensity of technology use for intensive-care nurses (Schaufeli, Keijsers and
Reis Miranda, 1995), case-load for social workers (Koeske and Koeske, 1989) and
psychologists (Skorupka and Agresti, 1993) and number of working hours per week for
nurses (Landsbergis, 1988). Most research, however, is on subjective workload. It has
been convincingly shown that perceived stress is positively related to burnout (Poulin and
Walter, 1993). This is not surprising, since, conceptually speaking, both variables are very
close.
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Role problems, more specifically role ambiguity and role conflict, are positively related
to burnout in members of many professions, such as nurses (Chiriboga and Bailey, 1986),
teachers (Fimian and Blanton, 1987), correctional officers (Whitehead, 1989), personnel
workers (Hopstaken and Buunk, 1989), and social workers (Himle, Jayarathne and Chess,
1987). Recently, the negative effects of role conflict and role ambiguity on burnout have
been confirmed in a longitudinal study among human services professionals (Lee and
Ashforth, 1993a).
A third job characteristic that is clearly positively related to burnout is lack of
autonomy (Landsbergis, 1988). Similar, but somewhat weaker, positive effects have only
occasionally been found for remaining job characteristics such as lack of feedback
(Astrom et al., 1990), monotony (Bussing and Perrar, 1992), lack of participation in
decision making (O’Driscoll and Schubert, 1988), lack of responsibility (Dolan and
Reinaud, 1992), poor opportunity for skill use (Richardsen, Burke and Leiter, 1992) and
poor physical work conditions (Friedman, 1991).
The above mentioned job characteristics relate not only to the occurrence of burnout,
but also to a variety of other health-related outcomes (Warr, 1987). In addition, two
specific job characteristics have been identified for burnout: (i) a bureaucratic work
organization and (ii) emotionally demanding relationships with recipients. For instance,
psychotherapists from outpatient clinics showed higher levels of burnout than their
independent colleagues who did not work in a bureaucratic environment (Radquepaw and
Miller, 1989). The effect of emotionally charged relationships is illustrated by a recent
study by Van Dierendonck, Schaufeli and Sixma (1994), which showed in a sample of
general practitioners that harassment by patients was indirectly related to burnout
through feelings of inequity (i.e. the imbalance of investments and outcomes in the
relationships with patients).

Job-Related Attitudes

Of all job-related attitudes, job dissatisfaction is the most highly and consistently
positively related to burnout (Friesen and Sarros, 1989). In a longitudinal study among
teachers, Wolpin, Burke and Greenglass (1991) showed that burnout leads to job
dissatisfaction rather than the other way around. In a somewhat similar vein, employees
who have elevated burnout scores report strong intentions to quit their jobs (Himle,
Jayarathne and Chess, 1987).
Typically, burnout occurs in individuals who are strongly personally involved in their
work with recipients but who are not involved in their jobs (Eisenstat and Felner, 1984).
Most probably, being involved in one’s work with recipients is emotionally demanding
and might thus be related to burnout. Higher levels of burnout are also observed among
employees who are poorly committed to their organization (e.g. Richardsen, Burke and
Leiter, 1992). Thus, burnout is frequently observed among employees who do not care
about their jobs or their organizations: they have withdrawn themselves cognitively.
Recently, Reilly (1994) showed that commitment moderates the relationship between
work stressors and emotional exhaustion: highly committed nurses are more sensitive to
work stressors than nurses who are low in commitment. Thus, nurses who identify with
the values and goals of their profession may react more strongly when distracted from
their ideals. Finally, unrealistic and high expectations about the job are found to be
322 W.M. SCHAUFELI AND B.P. BUUNK
positively related to burnout (Stevens and O’Neil, 1983).

Social Environment

The social environment in which burnout occurs includes not only recipients, but co-
workers, supervisors and probably subordinates as well. An abundance of empirical
studies confirms the negative relationship between burnout and social support. There is
longitudinal evidence for a main or direct effect of social support (Dignam, Barrera and
West, 1986; Kruger, Botman and Goodenow, 1991; Poulin and Walter, 1993), as well as
for an indirect or stress-buffering effect (Jayarathne, Himle and Chess, 1988). In the
latter case, social support has a beneficial effect on burnout but exclusively in the
presence of a stressor, whereas in the former case a positive effect is observed,
irrespective of the presence or absence of any particular stressor. It seems that support
from supervisors is more effective in alleviating burnout than support from co-workers
(Constable and Russell, 1986).
Moreover, poor team cohesion (Kruger, Botman and Goodenow, 1991) and
interpersonal conflicts at work (Leiter, 1991) are positively related to burnout. Hence, the
quality of the interactions with co-workers is important. In a similar vein, some limited
empirical evidence has been found for the existence of a ‘burnout culture’ (Golembiewski
and Munzenrider, 1988, pp. 156-157): the concentration of burned-out employees in
particular work groups. Some indications have been found that task-orientated
leadership style is positively related to burnout, whereas a more social-orientated style is
negatively related to burnout (O’Driscoll and Schubert, 1988).

Personality Characteristics

Most personality characteristics that have been associated with burnout are known from
the general stress literature (see Chapter 3, this volume): lack of hardiness (McCranie,
Lambert and Lambert, 1987), external locus of control (Keane, Ducette and Adler, 1985),
type A behaviour (Nagy and Davis, 1985), poor personal control (Papadatou,
Anagnostopoulos and Monos, 1994), neuroticism (McCranie and Brandsma, 1988), trait-
anxiety (Richardsen, Burke and Leiter, 1992) and poor self-esteem (Poulin and Walter,
1993). In addition, it has been observed that particular ways of coping, most notably
defensive strategies such as escape or avoidance, are positively related to burnout
(Thornton, 1992), whereas control orientated coping strategies are negatively related to
burnout (Koeske, Kirk and Koeske, 1993).
A small set of personality characteristics that pertain to the relationship with recipients
seems to be typical for burnout. For instance, Garden (1989) found that burnout is
associated with the Jungian ‘helping type’, which is over-represented in the human
services and is characterized by a need for affiliation, a capacity for warmth and a desire
for harmony. Furthermore, positive associations with burnout have been found with
empathy (Williams, 1989) and with poor communal orientation: a desire to give and
receive benefits in response to the needs of others (Van Yperen, Buunk and Schaufeli,
1992).
PROFESSIONAL BURNOUT 323
15.5.2 Symptoms and Consequences of Burnout

Some confusion exists about the difference between the symptoms and the consequences
of professional burnout. For example, is reduced personal accomplishment a symptom or
a consequence of burnout? This type of confusion was particularly obvious in the pioneer
phase, when clinical observations prevailed. In the empirical phase, when standardized
instruments were used to assess burnout, it became easier to make this distinction.
Nevertheless, the distinction remains rather arbitrary since it depends on the
conceptualization and operationalization of burnout. For instance, some burnout
measures include physical symptoms as well as organizational behaviours that may be the
consequence of burnout, whereas others do not (Schaufeli, Enzmann and Girault, 1993).
Hence, making a distinction between symptoms and consequences of burnout boils down
to drawing an arbitrary line. In fact, both symptoms and consequences can be viewed as
manifestations of burnout.
More than one hundred symptoms and consequences have been associated with
burnout, ranging from anxiety to lack of zeal (Schaufeli, 1990). Although the number and
the variety of these phenomena look rather impressive at first glance, it should be noted
that many symptoms come from uncontrolled clinical observations or from interview
studies with an impressionistic or unspecified analysis of the data.
Manifestations of burnout can be grouped for convenience into six major categories:
mental, physical, behavioural, social, attitudinal and organizational.

Mental Manifestations

Typically, the burned-out person’s emotional resources are exhausted and he or she feels
‘empty’, ‘trapped’ and ‘at the end of the rope’. Affective symptoms that relate to
depression are most prominent (i.e. depressed mood, helplessness, hopelessness and
meaninglessness) (Leiter, in press). A sense of failure, insufficiency and impotence is
observed, which eventually leads to poor self-esteem. The second type of affective
symptom relates to aggression and anxiety (Kahili, 1988). The burned-out person’s
frustration tolerance is diminished. He or she is irritable, over-sensitive, and behaves in a
hostile or suspicious manner, not only towards recipients, but also towards colleagues and
superiors. In addition, cognitive symptoms (e.g. inability to concentrate, forgetfulness,
difficulties in decision making) and sensori-motor symptoms (e.g. nervous tics,
restlessness, inability to relax) may be observed (Kahili, 1988). These cognitive and
sensori-motor symptoms are signs of high arousal and nervous tension.

Physical Manifestations

All kinds of indefinite physical complaints are observed, such as headaches, nausea and
muscle pains, particularly lower back pain (e.g. Belcastro, 1982). In addition, sexual
problems, sleep disturbances, loss of appetite and shortness of breath are reported by
individuals who suffer from burnout (Kahili, 1988). However, the most typical physical
manifestation of burnout is chronic fatigue (Shirom, 1989). Various psychosomatic
disorders seem to develop, such as ulcers, gastro-intestinal disorders and coronary heart
324 W.M. SCHAUFELI AND B.P. BUUNK
disease (Belcastro, Gold and Grant, 1982). Less serious but more frequently occurring are
prolonged colds and flu that cannot be shaken off (Paine,
1982) . It must be noted that virtually all studies have used self-report measures of
manifestations of burnout. To date, only one empirical study exists that shows that
burnout is associated with objectively measured physical symptoms (i.e. risk-factors for
cardiovascular disease; Melamed, Kushnir and Shirom, 1992). In addition, virtually no
study has employed an adequate longitudinal design. An exception is Wolpin (1986), who
showed that, after one year, burned-out teachers report significantly more somatic
complaints than teachers who were not considered burned-out.

Behavioural Manifestations

Individual behavioural manifestations are mainly caused by the person’s increased level
of arousal (e.g. hyperactivity, violent outbursts). An increased consumption of stimulants
like coffee and alcohol (Quattrochi-Tubin, Jones and Breedlove, 1982) is observed, as well
as substance abuse (Nowack and Pentkowski, 1994). In addition, particular health habits
such as physical activity and adequate diet are negatively related to burnout (Nowack,
Hanson and Gibbons, 1985).

Social Manifestations

Interpersonal problems at work occur with recipients, colleagues, supervisors and

subordinates (Pines and Maslach, 1978). Typically, the burned-out individual withdraws
from social contacts and is in danger of isolating himself or herself. Physical as well as
mental withdrawal from others is observed (Maslach and Pines, 1977). One of the most
obvious characteristics of burnout is the decreased involvement with recipients. This is
illustrated by the so-called ‘John Wayne syndrome’ that is observed among police officers:
playing the tough guy who is not moved or touched by anything he gets involved in during his
duty. Burned-out individuals might take their work problems home: negative spillover (Jackson
and Maslach, 1982). These problems come to dominate family life and might increase
interpersonal conflicts with spouse and children.

Attitudinal Manifestations

In addition to exhaustion, a dehumanizing, callous, detached, indifferent and cynical attitude

towards recipients is the most characteristic sign of burnout: That ulcer from room 34’
(Cummings and Nall, 1983). Such negative attitudes are particularly striking since initially the
relationship with recipients has been characterized by involvement, empathy, concern and
understanding (Pines and Kafry, 1978). By derogating and stereotyping recipients, and by
making sick jokes, one creates a psychological distance which protects or enhances the self
(Maslach, 1982a). Negative attitudes might also develop towards the job or the organization
(Richardsen, Burke and Leiter, 1992). The person’s initial intrinsic motivation has vanished; his
or her zeal, enthusiasm, interest and idealism are lost. When the challenge of the job dissipates,
boredom and dissatisfaction develop (Jayarathne and Chess, 1983). Burned-out individuals do
PROFESSIONAL BURNOUT 325
not feel appreciated by either the organization or by their colleagues. They have lost their
concern for the organization and now they are hypercritical, distrusting management, peers and
supervisors.

Organiza tional Manifesta tions

There exists some limited longitudinal evidence that burnout causes intention to quit, turnover
and absenteeism (Firth and Britton, 1989; Jackson, Schwab and Schuler, 1986). Lowered
individual productivity has been found among burned-out individuals (Golembiewski and
Munzenrider, 1988). On the other hand, the efficiency of intensive-care units has been found to
be better when the average level of burnout was higher among the nurses (Schaufeli, Keijsers
and Reis Miranda, 1995). Probably burned-out nurses are more obsessive and may therefore
make the unit run more efficiently. In that case, it may be hypothesized that these nurses show
the negative effects of burnout off the job. In other cross-sectional studies burnout has been
associated with tardiness, personal injuries and accidents, employee theft, neglect and on-the-
job mistakes (Kahili, 1988).

15.5.3 General Conclusions

Results from empirical research on the correlates and manifestations of burnout are quite
difficult to interpret because the field is rather scattered and the research findings often
contradict each other. Most probably this is due to sampling bias, the use of poorly
validated measures, inadequate research designs and—last but not least—the complexity
of the relationships involved. Nevertheless, it appears that factors in the work
environment, most notably workload and role problems, as well as job dissatisfaction and
lack of social support, are most strongly and consistently related to burnout. The strength
of these relationships is moderate, with Pearson correlation coefficients of about .40.
Generally, associations with other variables, including personality characteristics and
biographical features, are less strong (,20<r<.30).
Concerning the symptoms and consequences of burnout, it seems quite clear that the
mental, physical and behavioural manifestations are rather unspecific general stress
reactions. They can, for instance, also be observed after stressful life events like
unemployment or the death of a spouse. The specificity of the burnout syndrome lies, in
addition to its work-relatedness—the organizational manifestations—in the combination of
generic stress reactions with specific social and attitudinal symptoms.
Finally, it must be noted that the relatively few longitudinal studies, mentioned earlier,
point to three important conclusions that offer a refined perspective on the aetiology and
consequences of burnout. Firstly, lack of social support and role problems are antecedents
of burnout. Secondly, physical symptoms, job dissatisfaction, absenteeism, turnover and
lowered productivity may be consequences of burnout. In addition, it seems that burnout
is more a chronic than an acute state. Longitudinal studies show that levels of burnout do
not change very much across periods of up to two years (Burke and Greenglass, 1991;
Capel, 1991; Golembiewski, Deckard and Rountree, 1989; Greenglass and Burke, 1990;
Poulin and Walter, 1993; Wade, Cooley and Savicki, 1986; Wolpin, 1986).
326 W.M. SCHAUFELI AND B.P. BUUNK
15.6 THEORETICAL APPROACHES
Since burnout appeared on the stage first and foremost as a social problem, and not as a
scholarly construct, the main purpose was to find practical ways to combat burnout rather
than to understand the phenomenon from a theoretical point of view. However, as the
number of empirical studies rose sharply, the theoretical interest in burnout increased.
Initially, most theorizing was rather speculative and eclectic, borrowing concepts from
various psychological theories. Recently, more systematic theoretical approaches have
been developed, some of which are—at least partly—confirmed by empirical studies
(Schaufeli, Maslach and Marek, 1993). Nevertheless, a comprehensive theoretical
framework for burnout is still lacking. Probably, a single general and valid theory of
burnout will always remain an illusion in view of the complexity of the phenomenon.
This section distinguishes three theoretical approaches to burnout: (i) individual
approaches, emphasizing the role of intra-personal processes, (ii) interpersonal
approaches, focusing particularly on the unbalanced relationships that exist between
caregivers and recipients, and (iii) organizational approaches, stressing the relevance of the
wider organizational context for understanding burnout. Of course, these three types of
approaches are not mutually exclusive, and they differ mainly in the extent to which they
stress the importance of a particular type of factor in the development of the burnout
syndrome.

15.6.1 Individual Approaches

Without exception, the six individual approaches below are speculative since they are not
yet supported by empirical evidence. The first two approaches are mainly descriptive; the
remaining individual approaches are attempts to analyse burnout from more general
psychological perspectives that are either traditional (psychoanalysis and learning theory)
or more recent (action theory and conservation of resources theory). In one way or
another, all individual approaches emphasize the relevance of the discrepancy between
expectations and reality.

Burnout as Failure to Retain one's Idealized Self-Image

According to Freudenberger (1980), burnout (‘the super-achiever sickness’) develops

when individuals firmly believe in their idealized images of themselves as charismatic,
dynamic, inexhaustible and supercompetent persons. As a result, they lose touch
completely with their other, more fallible, ‘real’ selves. In vigorously trying to uphold
their idealized self-images, burnout candidates typically use the wrong strategies, which
further deplete their emotional resources. These ‘false cures’ are summarized by
Freudenberger in four Ds: disengagement, distancing, dulling and deadness.

Burnout as Progressive Disillusionment

The basic tenet of Edelwich and Brodsky’s (1980) approach is that the idealistic
expectations of the ‘helpers’ are frustrated. Although they recognize several other built-in
PROFESSIONAL BURNOUT 327
sources of frustration in the human services (e.g. lack of criteria for measuring
accomplishment, low pay, poor career prospects, inadequate institutional support, low
social status), the crucial role of initial unrealistic expectations and noble aspirations is
highlighted. According to Edelwich and Brodsky, four stages of progressive
disillusionment characterize the burnout process: (i) enthusiasm, (ii) stagnation (iii)
frustration, and (iv) apathy. A somewhat similar process has been described by Veninga
and Spradley (1981).

Burnout as a Narcissistic Disorder

According to Fischer (1983), individuals who have idealized their jobs and suffer
subsequent disillusionment could either reduce their ideals or leave the situation.
However, neither option is acceptable to burnout candidates. Instead of giving up or
reducing their ideals, or looking for another job, they redouble their efforts in order to
achieve their unrealistic objectives. They are motivated by the fear of having to give up
their narcissistic ‘illusion of grandiosity’, the erroneous notion of being special and
superior. The burnout candidate’s basic sense of self-esteem is grounded in this
narcissistic illusion. Accordingly, when a choice has to be made between giving up the
illusion of grandiosity or exhausting one’s resources, the burnout candidate opts for the
latter.

Burnout as a Pattern of Wrong Expectations

From the perspective of learning theory, burnout results from wrong expectations with
respect to: (i) reinforcements, (ii) outcomes and (iii) efficacy (Meier, 1983). Reinforcement
expectations are descriptions about whether certain work outcomes will meet one’s goals.
For example, a teacher might prefer to work with motivated students who frequently ask
questions. If these goals are too high, reinforcement expectations are not met and burnout
might develop. Outcome expectations are defined as descriptions about which behaviours
will lead to certain outcomes. For instance, a teacher may experience burnout because of
experiences that create the expectation that a class of students ‘simply cannot learn the
material’, thus drowning any hope for positive reinforcement from that class. Finally,
efficacy expectations refer to personal competence in executing the desired behaviour. For
instance, teachers can burn out because they feel that they lack the personal competence
necessary to teach adequately. Meier (1983) emphasizes that these three expectations
strongly depend on social and personal factors. For instance, group norms and personal
beliefs have a major impact on a person’s expectations, and thus, indirectly, on the
burnout process.

Burnout as Disturbed Action Process

Following German action theory, Burisch (1989,1993) considers the action episode as the
basic unit of analysis of his action model of burnout. The individual’s latent motives lie at
the core of action episodes that are activated by some perceived situation. In order to
328 W.M. SCHAUFELI AND B.P. BUUNK
reach the incentive, the actor engages in some action (that is, goal directed behaviour).
When the necessary cognitive and behavioural steps are taken and the goal is attained, the
motive becomes temporarily satiated. In that case, the action episode is considered
satisfactorily completed. However, according to Burisch, action episodes may be disturbed
in four different ways. Some obstacle may interfere with goal attainment, either calling
for unexpected high investments (goal impediment) or blocking the goal altogether (motive
thwarting). Alternatively, the goal may be obtained, but the rewards fail to meet
expectations (insufficient reward). Finally, unexpected negative side effects may occur.
Disturbed action episodes result in ‘first-order stress’, which may develop into ‘second-
order stress’ when attempts to remedy the situation repeatedly fail. Coping with second-
order stress and the concomitant loss of autonomy may be successful and lead to personal
growth, enhanced competence and so on. On the other hand, when coping fails a burnout
process is triggered: motives (e.g. of being an effective helper) may inflate or extinguish,
action planning may become inadequate, aspiration levels may shift downwards, feelings
of self-efficacy may decrease and demoralization may set in.

Burnout as Loss of Coping Resources

Conservation of resources (COR) theory is a basic motivational theory that postulates that
stress occurs: (i) when resources are threatened, (ii) when resources are lost or (iii) when
individuals invest in resources without the expected pay-off (Hobfoll, 1989). Resources are
defined rather broadly as valued objects (e.g. clothing, furniture), conditions (e.g.
employment, quality marriage), personal characteristics (e.g. social skills, hardiness) and
energies (e.g. stamina, knowledge). Since the basic tenet of COR theory is the utilization of
resources, and burnout is characterized by resource depletion, the COR perspective seems
quite relevant for understanding burnout. According to Hobfoll and Freedy (1993),
burnout is more likely to occur when resources are lost than when resources are not
gained. They call this the ‘primacy of loss’ and the ‘secondary importance of gain’,
respectively. For instance, for teachers, negative interactions with pupils, parents and
administrators—which imply losses on the interpersonal level—are more salient than the
everyday gains they receive from their job. When loss occurs, or when resources are
threatened, people are motivated to use their coping skills in order to regain resources or
to prevent losses. Viewed from this perspective, burnout—the depletion of emotional
resources—can be considered the ultimate price that has to be paid for the individual’s
active attempts to regain resources or to prevent their loss.

15.6.2 Interpersonal Approaches

The following two interpersonal approaches highlight the importance of emotional
demands in relationships with recipients, and the dynamics of social relationships at the
workplace. Traditionally, emotionally demanding interpersonal relationships of
professional caregivers with recipients have been considered to be the root cause of
burnout. However, it is important to broaden the social context and to include
relationships with others at the workplace as well, such as superiors and co-workers. Both
interpersonal approaches are described in somewhat more detail because they have
PROFESSIONAL BURNOUT 329
received, at least partly, empirical support.

Burnout as a Phased Reaction to Emotional Demands

According to Maslach (1982a, 1993), the burnout syndrome is initiated by emotionally

demanding relationships between caregivers and their recipients.
Particularly in the human services, these relationships are stressful by their very nature
since professionals are confronted with people’s needs, problems and suffering. This puts
a heavy psychological burden on them, which may drain their emotional resources,
eventually leading to emotional exhaustion, the first phase in the burnout process.
However, in order to cope with the emotional stresses, professionals generally develop an
attitude of ‘detached concern’; they learn to distance themselves from recipients in order
to help them better. Unfortunately, this survival strategy, which in fact is a professional
skill, does not develop adequately in every professional. Some of them overreact and
develop an impersonal, negative, callous and cynical attitude, in which initial concern has
given way to complete detachment. This so-called depersonalization constitutes the second
phase of the burnout process. It is considered to be a defensive coping strategy for dealing
with feelings of emotional exhaustion. This strategy further deteriorates the relationships
with recipients. Instead of reducing emotional strain, depersonalization increases
exhaustion. At that point, when the professional is continuously unsuccessful in achieving
his or her professional goals, because relationships with recipients have become
impoverished, feelings of reduced personal accomplishment may develop. This third and
final phase completes the downward spiral: diminished accomplishment further increases
emotional exhaustion, and, consequently, depersonalization.
The results of three earlier cross-sectional studies partly agree with this sequential
model of burnout (Leiter, 1988; Leiter and Maslach, 1988; Leiter and Meechan, 1986).
More particularly, the expected positive associations between emotionally demanding
relationships with recipients and emotional exhaustion, and between emotional exhaustion
and depersonalization have been confirmed. Byrne (1994), who employed causal
modelling techniques to test the sequential model of burnout on cross-sectional data,
confirmed the model in three independent teacher samples. However, recent work by
Leiter (1990,1991,1993) supports a mixed sequential and parallel model of burnout. His
‘developmental model’ defines emotional exhaustion as a reaction to occupational
stressors, of which work overload and interpersonal conflict are among the most
prominent. In Leiter’s model, depersonalization is a function of emotional exhaustion, as
outlined above. This means that emotional exhaustion mediates most of the impact of
environmental conditions on depersonalization. In contrast to the original phased reaction
model of Maslach (1982a), Leiter’s developmental model does not depict personal
accomplishment as a function of depersonalization. Rather, personal accomplishment is
positively influenced by the presence of resources such as social support, opportunities for
skill enhancement and participative decision making. Accordingly, two processes seem
important: (i) a sequential process, in which interpersonal work demands play a major
role and which leads to depersonalization through exhaustion, and (ii) a parallel process,
which is dominated by lack of resources and leads to diminished personal
accomplishment. A recent longitudinal study across eight months confirmed the first
process, as well as the somewhat independent role of personal accomplishment (Lee and
330 W.M. SCHAUFELI AND B.P. BUUNK
Ashforth, 1993b). The latter has been observed in cross-sectional studies as well (e.g.
Byrne, 1994; Koeske and Koeske, 1989).
Burnout as a Result of Social Comparison and Social Exchange
Processes

Basing themselves on social comparison theory (Schächter, 1959) and equity theory
(Walster, Walster and Berscheid, 1978), the central thesis of Buunk and Schaufeli (1993)
is that burnout develops primarily in the social context of a work organization. In order to
understand burnout, attention has to be paid to the way in which individuals compare
their own responses and feelings with those of others at work, and to how they evaluate
their psychological outcomes of and investments in the relationships with the recipients.
By definition, the relationship between caregiver and recipient is complementary,
which is nicely illustrated semantically by the terms ‘caregiver’ and ‘recipient’. The
former gives, the latter receives. However, according to equity theory (Walster, Walster
and Berscheid, 1978), people pursue reciprocity in interpersonal relationships: what they
invest in and gain from a relationship should be proportional to the investments and gains
of the other party in the relationship. Clearly, this is not the case in the human services:
the caregiver-recipient relationship is unbalanced in terms of costs and benefits or
investments and outcomes. This chronic disequilibrium, whereby caregivers continuously
put much more into relationships with their recipients than they receive in return, may
eventually deplete the professional’s emotional resources. It can be inferred from equity
theory that this lack of reciprocity and the resulting emotional exhaustion can be dealt
with—among other ways—by lowering the recipients’ outcomes; that is, by responding to
them in a depersonalized way. Indeed, significant correlations have been found between
perceptions of imbalance and burnout (particularly exhaustion and depersonalization) in
several occupational groups, such as nurses (Schaufeli and Janzcur, 1994; Van
Dierendonck and Schaufeli, 1993; Van Gorp, Schaufeli and Hopstaken, 1993), general
practitioners (Van Dierendonck, Schaufeli and Sixma, 1994) and correctional officers
(Schaufeli, Van den Eynden and Brouwers, 1994). The imbalance-burnout relationship
seems to be moderated by personality factors. For example, Van Yperen, Buunk and
Schaufeli (1992) found that nurses who felt that they invested highly in their relationship
with patients showed elevated levels of burnout only when they were low in communal
orientation, a personality characteristic that refers to a general responsiveness to the
needs of others.
In addition to emphasizing the importance of social exchange processes, Buunk and
Schaufeli (1993) argued, on the basis of social comparison theory, that human services
professionals, who—by the nature of their work—are faced with high emotional demands,
tend to compare their own emotional reactions to those of their co-workers. In particular,
individuals under stress seek out others for reasons of self-evaluation in order to assess the
appropriateness of their own reactions. Interestingly, Buunk and Schaufeli (1993) found,
as predicted, that nurses who felt uncertain at work showed an increased desire to affiliate
with others, but at the same time their actual affiliation decreased. They explain the latter
tendency towards social isolation, which is typical of burnout, by pointing to the fear of
embarrassment: talking about one’s doubts and uncertainties may be felt as admitting
inferiority.
It appears that especially the direction of social comparison with co-workers is related
PROFESSIONAL BURNOUT 331
to burnout. Upward comparison with others who are better off is associated with less
emotional exhaustion, particularly among individuals with high levels of self-esteem
(Buunk, Schaufeli and Ybema, 1994). Apparently, for these individuals their more
competent co-workers act as positive role models who provide information on how to cope
better with problems at work.
Finally, social comparison processes may contribute to the development and persistence
of burnout in particular work units. Buunk and Schaufeli (1993) hypothesized that a
process similar to emotional contagion may take place, in which individuals under stress
perceive symptoms of burnout in their colleagues and take on these symptoms, reasoning
that these symptoms are ‘normal’ given their stressful job situation. As expected,
particularly those with a strong need for social comparison appeared to be especially
sensitive to the perception of burnout symptoms, most notably emotional exhaustion
(Groenestijn, Buunk and Schaufeli, 1992). Moreover, nurses who perceived these
symptoms in their colleagues reported more burnout symptoms themselves.
Although the approach of Buunk and Schaufeli (1993) that considers the dynamics of
the social relationships at work at various levels seems to be a fruitful way to study
burnout, a longitudinal test of the hypotheses still stands out.

15.6.3 Organizational Approaches

Organizational approaches to burnout interpret the syndrome in terms of negative
organizational behaviour, which affects not only the individual but also the organization.
Three approaches are described, which differ in scope and in the degree to which they are
supported by empirical evidence. The first approach focuses on burnout among young
professionals, the second describes a phase model of progressive burnout, which has been
successfully tested in various organizational settings, and the final approach considers
burnout as the outcome of an unhealthy organization.

Burnout as Reality Shock

Cherniss (1980a,b) proposed a model of early career burnout based on interviews with
human service professionals at the start of their career. The basic tenet of his model is
that particular work setting characteristics interact with personal characteristics to
produce particular stressors. Whether burnout develops depends on how professionals
cope with these stressors: active problem solving is superior to defensive strategies such as
avoiding. Accordingly, burnout is a process that develops over time and represents one
way of adapting to particular sources of organizational stress.
Cherniss distinguishes between eight negative work setting characteristics:
1. the absence of an orientation or introduction programme for new employees
2. high workload
3. understimulation
4. limited scope of client contact
5. low level of autonomy
6. discrepancy between institutional goals and personal values
7. inadequate leadership and supervisory practices
332 W.M. SCHAUFELI AND B.P. BUUNK
8. social isolation
In addition, two kinds of personal characteristics are mentioned: resources outside of
work and career orientation. The latter includes ‘social activists’ (who want to change the
world), ‘careerists’ (who want to make money), ‘artisans’ (who are intrinsically
motivated) and ‘self-investors’ (for whom the job is a necessary evil). According to
Chemiss, the major sources of stress that are brought about by the interaction of work
setting and person are: (i) uncertainty and doubts about one’s competence, (ii) problems
with recipients, (iii) bureaucratic infringement on one’s autonomy, (iv) lack of challenge
and fulfilment, and (v) lack of collegiality. In the process of adapting to these stressors,
which are rather typical of the human services, Cherniss observed in young professionals
negative changes in attitudes and outlook that are indicative of burnout: reduced
aspirations and responsibility, loss of idealism, increased cynicism and pessimism,
increased emotional detachment, withdrawal from work and growing concern with the
self.
Cross-sectional studies among police officers (Burke, Shearer and Deszca, 1984) and
teachers (Burke and Greenglass, 1989a) support the validity of the model. As expected,
path analysis showed two significant indirect paths from work setting characteristics and
personal characteristics to burnout, both through experienced sources of stress. In
addition, significant direct paths were found from work setting and personal
characteristics to burnout. Furthermore, Burke and Greenglass (1988) showed that
teachers who described themselves as ‘social activists’ had the highest burnout scores,
which is compatible with the view of burnout as a process of progressive disillusionment.
Cherniss (1989) re-interviewed the same professionals ten years after he developed his
model in order to explore the relationship between the degree of burnout experienced
during the first year of the career and career adaptation during the next decade. His
results show that those who were more burned-out early in their careers were less likely
to change careers and were more flexible in their approach to work. Thus, the follow-up
study suggests that early career burnout does not lead to any significant negative long-
term consequences.

Burnout as a Virulent Process

Essentially, the approach of Golembiewski and his colleagues is rather straightforward

(Golembiewski and Munzenrider, 1988): they consider burnout as a virulent process that
develops progressively through eight phases. It is claimed that the burnout process might
be set in motion by various different job stressors (e.g. overload, lack of autonomy,
conflicts with co-workers or supervisors). Moreover, it is assumed that burnout leads to
poor physical health, reduced productivity and poor work performance. Golembiewski
agrees with the three-dimensionality of the burnout syndrome as proposed by Maslach
(1982a) but does not agree with her sequential model. Instead, he distinguishes eight
progressive phases of burnout. Depersonalization is considered the least important
contributor to burnout, followed by lack of personal accomplishment and emotional
exhaustion. Dichotomizing the distribution of MBI scale scores at the median as high and
low generates eight phases of burnout (Table 15.1). It is important to note that although
the virulence of burnout increases from phase I to phase VIII, individuals do not
PROFESSIONAL BURNOUT 333
necessarily need to follow the successive stages. Since no theoretical rationale is presented,
Golembiewski’s approach remains purely descriptive.
The categorization in eight phases boils down to reducing all possible combinations of
MBI scores (over 80000!) on an eight-point scale. When depersonalization, reduced
personal accomplishment and emotional exhaustion are assigned weights of 1,2 and 4,
respectively, and these weights are added for every phase, an eight-point rating scale
emerges ranging from 0 (phase I) to 7 (phase VIII) (Burisch, 1989, p. 20). Accordingly,
the phase model is heavily biased towards emotional exhaustion (Lei ter, 1993).
Research based on the phase model in organizations has followed three lines. Most
studies have attempted to validate the notion of progressive phases of burnout. Overall,
these attempts have been quite successful: individuals in more advanced phases almost
always report more negative work experiences (e.g. greater stress, less autonomy, more
conflicts and role problems, less support) and more negative outcomes (e.g. job
dissatisfaction, psychosomatic symptoms, higher turnover intentions, less job
involvement, decreased productivity) (e.g. Burke and Deszca, 1986; Burke and
Greenglass, 1989b; Golembiewski and Munzenrider, 1984; 1988; Golembiewski,
Munzenrider and Carter, 1983). Some of these results have been replicated in cross-
national studies (Golembiewski, Scherb and Boudreau, 1993). A second stream of
research indicates that the incidence of burnout in various phases differs across
organizations. For instance, the range of respondents in phase VIII varies from 6% to
29% (Golembiewski and Munzenrider, 1988). Moreover, burnout

Table 15.1 Progressive phases of burnout

Factor* 1 II III IV V VI VII VIII
DEP Low High Low High Low High Low High
PA(r) Low Low High High Low Low High High
EE Low Low Low Low High High High High
* DEP=MBI depersonalization; PA(r)=MBI personal accomplishment (reduced); EE=MBI emotional
exhaustion.
Source: Golembiewski, R.T. and Munzenrider, R.F. (1988) Phases of burnout: Developments in concepts and
applications. Reproduced by permission of Greenwood Publishing Group Inc., Westport,
tends to cluster in particular work groups: 83% of the employees in the most advanced
phase are employed in work groups where more than 50% of their colleagues are assigned
to an advanced phase as well (Rountree, 1984). Finally, phase assignments are fairly stable
across time: 40% are assigned to the same phase one year later, whereas 55% move only
one phase up or down (Golembiewski and Boss, 1991). Individuals moving to a lower
burnout phase reported corresponding improvements in antecedents (i.e. work setting
characteristics) and consequences (greater job satisfaction and fewer psychosomatic
symptoms) (Burke and Greenglass,
1991).

Burnout as a Consequence of Organizational Unhealthiness

It is generally believed that the quality of the organization, of the work environment and
of the work itself may affect the experience of stress and employee health. Following this
line of reasoning, Cox, Kuk and Leiter (1993) assumed that the healthiness of the
334 W.M. SCHAUFELI AND B.P. BUUNK
organization is related to the employees’ level of burnout. They maintain that the
healthiness of an organization is a reflection of the ‘goodness’ of its psychosocial
subsystems and of their coherence and integration. More particularly, their study dealt
with the school as subjective organization and suggested that three psychosocial
subsystems could be distinguished: (i) the task environment, (ii) the problem solving
environment and (iii) the developmental environment. It appeared that the quality of the
task environment and of the problem solving environment were directly related to
burnout. Moreover, evidence was found for a moderator effect of task and developmental
environments on the relationship between teacher stress and burnout. This suggests that
experiencing good task and developmental environments at school may attenuate the
effects of work stress on burnout.

15.7 INTERVENTIONS
From the moment burnout was introduced in the early 1970s, there has been a vivid
interest in interventions. There is an extensive, albeit kaleidoscopic and rather scattered,
literature on burnout interventions, which suggests that virtually every approach from the
occupational stress area can be used to prevent or reduce burnout. Essentially, two
general approaches can be distinguished: individual interventions and workplace
interventions (Ross and Altmaier, 1994). Although almost every author on the subject
acknowledges that a combination of both approaches would be most effective, the vast
majority of burnout interventions have been conducted on the individual level. A strictly
individual approach to burnout creates the danger that a ‘blame the victim’ situation is
created. This criticism clearly applies to the popular burnout workshops that combine
several individual approaches. This concluding section briefly reviews individual and
workplace interventions that have been applied to burnout, then discusses the results of
empirical studies on the effectiveness of burnout interventions.
15.7.1 Individual and Workplace Interventions
Individual approaches to prevent or reduce burnout include cognitive-behavioural
techniques such as stress inoculation training, rational emotive therapy, cognitive
restructuring and behavioural rehearsal (Edelwich and Brodsky, 1980). A cognitively
orientated approach is relevant because burnout often involves ‘wrong’ cognitions such as
unrealistic expectations and false hopes. In addition, relaxation techniques and didactic
stress management are often used to reduce burnout (Jaffe and Scott, 1989). The latter
involves the presentation of theoretical information about burnout and includes
techniques such as self-monitoring. Time management, physical training, dieting and
increasing one’s social skills, particularly assertiveness, have been recommended to
combat burnout (Maslach, 1982b). In order to counteract the reality shock that is
experienced by many new professionals, preparatory training programmes may provide
them with more realistic images of their profession, instead of fostering wrong
expectations (Cunningham, 1983). Mutual aid groups are advocated for self-help
(Spicuzza and De Voe, 1982). Preferably these groups should be initiated by the
professionals themselves, rather than by their management (Cherniss and Dantzig, 1986).
Only occasionally are workplace interventions explicitly carried out in order to reduce
stress or burnout. Generally, other purposes are targeted such as increased productivity
PROFESSIONAL BURNOUT 335
and efficiency, cost-effectivenes, smooth communication or organizational flexibility.
Nevertheless, there is an increasing awareness that preventing stress at the workplace is
important because of the high direct and indirect costs that are associated with it
(International Labour Organization, 1992). As far as burnout is concerned, workplace
interventions are even less specifically described than individual approaches.
Work redesign (i.e. job enlargement, job rotation and job enrichment)is mentioned as a
major tool to decrease quantitative and qualitative workload (Pines and Maslach, 1978).
Another way to reduce qualitative workload is to follow additional training courses (e.g.
‘How to deal with violent clients’). Since many burnout candidates feel ‘locked in’ their
careers, career development programmes and career counselling would be other
organizational approaches to prevent burnout. Especially in order to avoid early career
burnout, Cherniss (1980a) proposed an introductory mentorship system. Bidirectional
communication between management and employees, adequate procedures for conflict
management and participative decision making have been proposed as antidotes to
burnout as well (Cherniss, 1980a). Moreover, social support from colleagues and
superiors should beinstitutionalizedin the form of regular consultations and meetings
(Pines and Maslach, 1978). In addition, ‘time-outs’ and sabbatical leaves have been
suggested in order to enhance recuperation from the daily stresses of the job (Pines and
Kafry, 1982). Finally, Golembiewski, Hilles and Rick (1987) describe an organizational
development (OD) approach to burnout that strengthened the workers’ social network for
participatory change through problem confrontation, group consolidation around
problems and building consensus for change. According to Karasek and Theorell (1990,
pp. 239-241), this approach essentially reduces job demands and increases worker control.
15.7.2 The Effectiveness of Burnout Interventions
With two notable exceptions, evaluation studies exclusively involve individually orientated
programmes. Pines and Maslach (1980) describe a successful workplace intervention to
reduce burnout by redesigning the jobs of professionals working at a day-care centre for
children. Unfortunately, they do not present quantitative data. In contrast, Golembiewski,
Hilles and Rick (1987) were able to show a positive effect on burnout and turnover rates
of their organizational development programme, which was conducted in the human
services department of a pharmaceuticals company. Unfortunately, the effect on burnout
was not retained after the firm went through a process of reorganization.
The effectiveness of individual approaches to combating burnout has been studied
somewhat more intensively. For instance, Freedy and Hobfoll (1994) used stress
inoculation training among nurses to enhance their social support and individual mastery
resources. Participants experienced significant enhancements in social support and
mastery compared to the no-intervention control group. In particular, nurses with low
initial levels on both resources showed significant reductions in emotional exhaustion and
depression. Similar positive results were obtained by West, Horan and Games (1984), who
used didactic stress management, training coping skills (i.e. relaxation, assertiveness,
cognitive restructuring and time management) and exposure via role playing. A four-
month follow-up showed that burnout (i.e. emotional exhaustion and reduced personal
accomplishment) decreased significantly, as did anxiety and systolic blood pressure. More
detailed analysis revealed that coping skills were the principal ingredient of the
programme. In another controlled study, Higgins (1986) showed that learning palliative
coping skills (i.e. progressive relaxation and systematic desensitization) was equally
336 W.M. SCHAUFELI AND B.P. BUUNK
effective as cognitive and behavioural skills training (i.e. time management, assertiveness
training and rational emotive therapy) in reducing levels of emotional exhaustion.
However, Corcoran and Bryce (1983) showed that a behaviourally oriented human
resource development programme was slightly superior to a more cognitively oriented
microcounselling training programme in reducing levels of emotional exhaustion.
Pines and Aronson (1983) evaluated a one-day burnout workshop for employees of two
social services, which combined several individual approaches, e.g. relaxation techniques,
cognitive stress management, time management, social skills training, didactical stress
management and attitude change. The participants’ level of exhaustion decreased slightly
but not significantly. However, compared to the control group, which did not participate
in the workshop, satisfaction with co-workers went up significantly in the experimental
group. Schaufeli (1995) evaluated a somewhat similar burnout workshop for community
nurses but found that only the symptom levels (i.e. emotional exhaustion, psychological
strain and somatic complaints) of the participating nurses decreased significantly.
However, no significant changes were observed in levels of the attitudinal component of
burnout (depersonalization and reduced personal accomplishment). In addition, it was
observed that nurses who were rather resistant to stress benefited most from the
workshop. Finally, the effects of mutual aid groups were evaluated by two studies that
consistently showed that levels of burnout did not decrease (Brown, 1984; Larson, 1986).
However, participants were satisfied about the programme and about the group
experience, and had become more content with their co-workers and superiors.
It is rather difficult to draw general conclusions about the effectiveness of individual
burnout interventions since the evaluation studies use different samples, procedures, time
frames, measurement instruments and training methods. Besides, some studies suffer
from methodological inadequacies such as the lack of control groups and the small
number of participants. Nevertheless, one major conclusion emerges: the core symptom of
burnout—exhaustion—can be reduced by training professionals to use particular coping
skills, most notably relaxation techniques and cognitive restructuring. On the other hand,
personal accomplishment, and particularly depersonalization, seem rather resistant to
change. Providing social support—as staff support groups do—does not seem to have a
positive impact on burnout, although the programmes are evaluated positively and
satisfaction with colleagues seems to increase.

15.8 CONCLUSION
Two decades after its introduction, burnout, which was initially recognized as a social
problem, has developed into a prospering research area. The concept has successfully
penetrated from practice into the realm of academic psychology. Some major
achievements have been made. Most importantly, a consensual agreement has developed
on an operational definition of burnout in the human services. This is exemplified by the
almost universal use of the MBI as a measurement tool. In addition, this chapter shows
that much progress has been made on the empirical as well as on the conceptual level.
However, much work remains to be done. There is still a great need for research that is
theory-driven, longitudinal and includes other than self-report measures. Moreover, valid
tools for individual assessment have to be developed as well as specific—organizational—
interventions. Finally, and most importantly, to date burnout has predominantly been
PROFESSIONAL BURNOUT 337
studied among human services professionals. However, it becomes increasingly clear that
workers from other occupational fields might suffer from the syndrome as well.
Accordingly, our challenge for the coming years is to expand burnout research beyond the
occupational area in which it first emerged.

ACKNOWLEDGEMENT
The authors wish to express their gratitude to Esther R. Greenglass for her thoughtful
comments on an earlier version of this chapter.
PROFESSIONAL BURNOUT 338
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